| Inpatient Physician and Surgical Services | 30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $15.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | 30.00% Coinsurance after deductible |
| Nutritional Counseling | 30.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | 50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 30.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $800.00 Copay after deductible |
| Outpatient Rehabilitation Services | $75.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 30.00% Coinsurance after deductible |
| Radiation | $100.00 Copay after deductible |
| Reconstructive Surgery | $800.00 Copay after deductible |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 30.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | 30.00% Coinsurance after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | 30.00% Coinsurance after deductible |
| Chemotherapy | $750.00 Copay after deductible |
| Chiropractic Care | Not covered |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 30.00% Coinsurance after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | 30.00% Coinsurance after deductible |
| Dialysis | $500.00 Copay after deductible |
| Durable Medical Equipment | 30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $1000.00 Copay after deductible |
| Eye Glasses for Children | 30.00% Coinsurance after deductible |
| Gender Affirming Care | $800.00 Copay after deductible |
| Habilitation Services | $75.00 Copay after deductible |
| Hearing Aids | Not covered |
| Home Health Care Services | 30.00% Coinsurance after deductible |
| Hospice Services | 30.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | $200.00 Copay after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | $100.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $75.00 Copay after deductible |
| Rehabilitative Speech Therapy | $75.00 Copay after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $30.00 |
| Transplant | 30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | Not covered |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $35.00 Copay after deductible |