| Outpatient Rehabilitation Services | $100.00 |
| Prenatal and Postnatal Care | $45.00 |
| Accidental Dental | 50.00% Coinsurance after deductible |
| Allergy Testing | $120.00 |
| Bariatric Surgery | $1,200.00 |
| Chemotherapy | $700.00 |
| Chiropractic Care | $45.00 |
| Clinical Trials | $45.00 |
| Delivery and All Inpatient Services for Maternity Care | $3,000.00 |
| Diabetes Care Management | $45.00 |
| Diabetes Education | 50.00% |
| Diagnostic Breast Cancer Imaging | No charge |
| Dialysis | $500.00 |
| Durable Medical Equipment | 50.00% |
| Emergency Transportation/Ambulance | $2,200.00 |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | $45.00 |
| Habilitation Services | $100.00 |
| Hearing Aids | 50.00% |
| Home Health Care Services | 50.00% |
| Hospice Services | $3,000.00 |
| Imaging (CT/PET Scans, MRIs) | $400.00 |
| Infertility Treatment | 50.00% |
| Infusion Therapy | $120.00 |
| Inherited Metabolic Disorder - PKU | 50.00% |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $45.00 |
| Nutritional Counseling | $45.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 50.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $700.00 |
| Private-Duty Nursing | $45.00 |
| Prosthetic Devices | 50.00% |
| Radiation | $120.00 |
| Reconstructive Surgery | $3,000.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $100.00 |
| Rehabilitative Speech Therapy | $100.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | $3,000.00 Copay per Stay |
| Substance Abuse Disorder Inpatient Services | $3,000.00 |
| Substance Abuse Disorder Outpatient Services | $45.00 |
| Transplant | $3,000.00 |
| Treatment for Temporomandibular Joint Disorders | 50.00% |
| Virtual Visits/Now Clinic | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $120.00 |