| Bariatric Surgery | $750.00 Copay per Stay after deductible |
| Routine Eye Exam for Children | $55.00 |
| Routine Foot Care | $55.00 |
| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | $400.00 Copay after deductible |
| Allergy Testing | $55.00 |
| Basic Dental Care - Child | 25.00% Coinsurance after deductible |
| Chemotherapy | $75.00 |
| Chiropractic Care | $55.00 |
| Delivery and All Inpatient Services for Maternity Care | $750.00 Copay per Stay after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $55.00 |
| Dialysis | No Charge after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | No Charge after deductible |
| Eye Glasses for Children | 20.00% Coinsurance after deductible |
| Habilitation Services | $55.00 |
| Hearing Aids | 20.00% Coinsurance after deductible |
| Home Health Care Services | No Charge after deductible |
| Hospice Services | No Charge after deductible |
| Imaging (CT/PET Scans, MRIs) | $300.00 Copay after deductible |
| Infertility Treatment | $55.00 |
| Infusion Therapy | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $50.00 Copay after deductible |
| Major Dental Care - Child | 50.00% Coinsurance after deductible |
| Nutritional Counseling | $55.00 |
| Orthodontia - Child | 50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $35.00 |
| 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 | $75.00 |
| Reconstructive Surgery | $500.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $55.00 |
| Rehabilitative Speech Therapy | $55.00 |
| Routine Eye Exam (Adult) | $55.00 |
| 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 | $35.00 |
| Transplant | $750.00 Copay per Stay after deductible |
| Treatment for Temporomandibular Joint Disorders | $500.00 Copay after deductible |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $75.00 Copay after deductible |