| Infusion Therapy | No Charge after deductible |
| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $55.00 |
| Allergy Testing | $55.00 |
| Bariatric Surgery | $750.00 Copay after deductible |
| Bone Marrow Transplants for Treatment of Breast Cancer | $750.00 Copay after deductible |
| Cardiac Rehabilitation | $55.00 |
| Chemotherapy | No Charge after deductible |
| Chiropractic Care | $55.00 |
| Clinical Trials | $750.00 Copay after deductible |
| Congenital Anomaly, including Cleft Lip/Palate | $750.00 Copay after deductible |
| Contraceptive Services | No charge |
| Delivery and All Inpatient Services for Maternity Care | $750.00 Copay after deductible |
| Diabetes Care Management | $55.00 |
| Diabetes Education | $55.00 |
| Dialysis | No Charge after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Early Intervention Services | No charge |
| Emergency Transportation/Ambulance | No Charge after deductible |
| Eye Glasses for Children | 35.00% Coinsurance after deductible |
| Habilitation Services | $55.00 |
| Hearing Aids | No charge |
| Home Health Care Services | No Charge after deductible |
| Hormone Replacement Therapy (HRT) | $55.00 |
| Hospice Services | No Charge after deductible |
| Human Leukocyte Antigen Testing | $25.00 Copay after deductible |
| Hypodermic Syringes or Needles | $50.00 Copay after deductible |
| Imaging (CT/PET Scans, MRIs) | $300.00 Copay after deductible |
| Infertility Treatment | $500.00 Copay after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $25.00 Copay after deductible |
| Nutrition/Formulas | No Charge after deductible |
| Nutritional Counseling | $55.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $30.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $500.00 Copay after deductible |
| Outpatient Rehabilitation Services | $55.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | No Charge after deductible |
| Reconstructive Surgery | $750.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $55.00 |
| Rehabilitative Speech Therapy | $55.00 |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | $750.00 Copay per Stay after deductible |
| Substance Abuse Disorder Inpatient Services | $750.00 Copay per Stay after deductible |
| Substance Abuse Disorder Outpatient Services | $30.00 |
| Transplant | $750.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | $55.00 |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $75.00 Copay after deductible |