| Orthodontia - Child | Not covered |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $50.00 Copay after deductible |
| Acupuncture | Not covered |
| Allergy Testing | $25.00 Copay after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | $50.00 Copay after deductible |
| Chiropractic Care | $50.00 Copay after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 40.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | $25.00 Copay after deductible |
| Dialysis | $50.00 Copay after deductible |
| Durable Medical Equipment | 15.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $50.00 Copay after deductible |
| Eye Glasses for Children | $50.00 Copay after deductible |
| Habilitation Services | $50.00 Copay after deductible |
| Hearing Aids | 15.00% Coinsurance after deductible |
| Home Health Care Services | $50.00 Copay after deductible |
| Hospice Services | $50.00 Copay after deductible |
| Imaging (CT/PET Scans, MRIs) | 40.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | $50.00 Copay after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $25.00 Copay after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | Not covered |
| Orthodontia - Adult | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $25.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $50.00 Copay after deductible |
| Prenatal and Postnatal Care | $50.00 Copay after deductible |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 15.00% Coinsurance after deductible |
| Radiation | $50.00 Copay after deductible |
| Reconstructive Surgery | 40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $50.00 Copay after deductible |
| Rehabilitative Speech Therapy | $50.00 Copay after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | $50.00 Copay after deductible |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $25.00 |
| Transplant | 40.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | $50.00 Copay after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $25.00 Copay after deductible |