| Other Practitioner Office Visit (Nurse, Physician Assistant) | $30.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 25.00% |
| Acupuncture | Not covered |
| Allergy Testing | $55.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | 40.00% |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $0.00 |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | $0.00 |
| Dialysis | $0.00 |
| Durable Medical Equipment | 40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 25.00% |
| Eye Glasses for Children | No charge |
| Habilitation Services | $30.00 |
| Hearing Aids | 40.00% Coinsurance after deductible |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | $0.00 |
| Imaging (CT/PET Scans, MRIs) | $0.00 |
| Infertility Treatment | Not covered |
| Infusion Therapy | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $30.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $0.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Outpatient Rehabilitation Services | $30.00 |
| Prenatal and Postnatal Care | $15.00 |
| Private-Duty Nursing | 40.00% Coinsurance after deductible |
| Prosthetic Devices | 40.00% Coinsurance after deductible |
| Radiation | $0.00 |
| Reconstructive Surgery | 25.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 |
| Rehabilitative Speech Therapy | $30.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $60.00 |
| Skilled Nursing Facility | $0.00 |
| Substance Abuse Disorder Inpatient Services | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $0.00 |
| Transplant | $0.00 |
| Treatment for Temporomandibular Joint Disorders | 40.00% |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $0.00 |