| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 50.00% Coinsurance after deductible |
| Acupuncture | No charge |
| Allergy Testing | No charge |
| Attention Deficit Disorder | No charge |
| Autism Spectrum Disorders | No charge |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Cancer Monitoring Screening | 50.00% Coinsurance after deductible |
| Cardiac Rehabilitation | No charge |
| Chemotherapy | 50.00% Coinsurance after deductible |
| Chiropractic Care | No charge |
| Clinical Trials | 50.00% Coinsurance after deductible |
| Congenital Anomaly, including Cleft Lip/Palate | 50.00% Coinsurance after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 50.00% Coinsurance after deductible |
| Dental Anesthesia | 50.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Dental Services for Children with Severe Disabilities | 50.00% Coinsurance after deductible |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | 50.00% Coinsurance after deductible |
| Doula | No charge |
| Durable Medical Equipment | No charge |
| Emergency Transportation/Ambulance | 50.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | Not covered |
| Habilitation Services | No charge |
| Hearing Aids | 50.00% Coinsurance after deductible |
| Home Health Care Services | 50.00% Coinsurance after deductible |
| Hospice Services | No Charge after deductible |
| Imaging (CT/PET Scans, MRIs) | 50.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 50.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU | 50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | 50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Newborn Hearing Screening | No charge |
| Nutritional Counseling | No charge |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | No charge |
| Outpatient Rehabilitation Services | No charge |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 50.00% Coinsurance after deductible |
| Prosthetic Devices | 50.00% Coinsurance after deductible |
| Pulmonary Rehabilitation | 50.00% Coinsurance after deductible |
| Radiation | 50.00% Coinsurance after deductible |
| Reconstructive Surgery | 50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $100.00 |
| Rehabilitative Speech Therapy | $100.00 |
| Reversible Contraveptives | 50.00% Coinsurance after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $100.00 |
| School Based Health Centers | No charge |
| Skilled Nursing Facility | 50.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $40.00 |
| Transplant | 50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | Not covered |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 50.00% Coinsurance after deductible |