| Cosmetic Surgery | 30.00% Coinsurance after deductible |
| Telehealth - Specialist | No charge |
| Transplant | 30.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $50.00 |
| Acupuncture | $25.00 |
| Allergy Testing | $50.00 |
| Chemotherapy | $50.00 |
| Chiropractic Care | $25.00 |
| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | 30.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | 30.00% Coinsurance after deductible |
| Diabetes Education | $20.00 |
| Dialysis | $50.00 |
| Durable Medical Equipment | 30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 30.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $50.00 |
| Hearing Aids | 30.00% |
| Home Health Care Services | 30.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $350.00 Copay after deductible |
| Infusion Therapy | $50.00 |
| Inpatient Physician and Surgical Services | 30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $50.00 |
| Nutritional Counseling | $20.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $20.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $50.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 30.00% Coinsurance after deductible |
| Radiation | $50.00 |
| Reconstructive Surgery | 30.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $50.00 |
| Rehabilitative Speech Therapy | $50.00 |
| Routine Eye Exam (Adult) | $20.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $50.00 |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $20.00 |
| Telehealth - Primary Care | No charge |