| Delivery and All Inpatient Services for Maternity Care | 35.00% Coinsurance after deductible |
| Diabetes Education | 35.00% Coinsurance after deductible |
| Dialysis | 35.00% Coinsurance after deductible |
| Durable Medical Equipment | 35.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 35.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 35.00% Coinsurance after deductible |
| Habilitation Services | $40.00 |
| Hearing Aids | 35.00% Coinsurance after deductible |
| Home Health Care Services | 35.00% Coinsurance after deductible |
| Hospice Services | 35.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 35.00% Coinsurance after deductible |
| Infusion Therapy | 35.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 35.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 35.00% Coinsurance after deductible |
| Nutritional Counseling | 35.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $20.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 35.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $40.00 |
| Prenatal and Postnatal Care | 35.00% Coinsurance after deductible |
| Prosthetic Devices | 35.00% Coinsurance after deductible |
| Radiation | 35.00% Coinsurance after deductible |
| Reconstructive Surgery | 35.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $40.00 |
| Rehabilitative Speech Therapy | $40.00 |
| Routine Eye Exam (Adult) | $10.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | 35.00% Coinsurance after deductible |
| Skilled Nursing Facility | 35.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 35.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $20.00 |
| Transplant | 35.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 35.00% Coinsurance after deductible |
| Chiropractic Care | $40.00 |
| Allergy Testing | 35.00% Coinsurance after deductible |
| Chemotherapy | 35.00% Coinsurance after deductible |
| Accidental Dental | 35.00% Coinsurance after deductible |