| Habilitation Services | $45.00 |
| Hearing Aids | 30.00% |
| Hearing Exams | $10.00 |
| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $10.00 |
| Chemotherapy | $45.00 |
| Chiropractic Care | $10.00 |
| Cosmetic Surgery | $450.00 Copay after deductible |
| Delivery and All Inpatient Services for Maternity Care | 30.00% Coinsurance after deductible |
| Dental Anesthesia | $450.00 Copay after deductible |
| Diabetes Care Management | $10.00 |
| Diabetes Education | $10.00 |
| Dialysis | $10.00 |
| Durable Medical Equipment | 30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 30.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 30.00% Coinsurance after deductible |
| Home Health Care Services | 30.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | 30.00% Coinsurance after deductible |
| Infertility Treatment | 30.00% Coinsurance after deductible |
| Infusion Therapy | $10.00 |
| Inherited Metabolic Disorder - PKU | 30.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $40.00 |
| Nutritional Counseling | $10.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $10.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $450.00 Copay after deductible |
| Outpatient Rehabilitation Services | $45.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 30.00% Coinsurance after deductible |
| Radiation | $45.00 |
| Reconstructive Surgery | $450.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $45.00 |
| Rehabilitative Speech Therapy | $45.00 |
| Routine Eye Exam (Adult) | $10.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $45.00 |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $10.00 |
| Transplant | 30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | $10.00 |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $45.00 |