| Routine Eye Exam for Children | No charge |
| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $5.00 |
| Allergy Testing | 20.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies | 20.00% Coinsurance after deductible |
| Autism Spectrum Disorders - Assessment and Evaluation Services | $50.00 |
| Bariatric Surgery | 20.00% Coinsurance after deductible |
| Basic Dental Care - Child | No charge |
| Chemotherapy | 20.00% Coinsurance after deductible |
| Chiropractic Care | $5.00 |
| Delivery and All Inpatient Services for Maternity Care | 20.00% Coinsurance after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $50.00 |
| Diabetic Supplies | 20.00% Coinsurance after deductible |
| Dialysis | 20.00% Coinsurance after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $250.00 Copay after deductible |
| Eye Glasses for Children | 20.00% Coinsurance after deductible |
| Gender Affirming Care | 20.00% Coinsurance after deductible |
| Habilitation Services | $50.00 |
| Hearing Aids | 20.00% Coinsurance after deductible |
| Home Health Care Services | 20.00% Coinsurance after deductible |
| Hospice Services | 20.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 20.00% Coinsurance after deductible |
| Infertility Treatment | 20.00% Coinsurance after deductible |
| Infusion Therapy | 20.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 20.00% Coinsurance after deductible |
| Inpatient Rehabilitation | 20.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $10.00 |
| Major Dental Care - Child | No charge |
| Nutritional Counseling | 20.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 20.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $50.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 20.00% Coinsurance after deductible |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Prosthetics: Legs and Arms | 20.00% |
| Prosthetics: Recreational | 20.00% Coinsurance after deductible |
| Radiation | 20.00% Coinsurance after deductible |
| Reconstructive Surgery | 20.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $50.00 |
| Rehabilitative Occupational Therapy | $50.00 |
| Rehabilitative Physical Therapy | $50.00 |
| Rehabilitative Speech Therapy | $50.00 |
| Skilled Nursing Facility | 20.00% Coinsurance after deductible |
| Standalone Laboratory | $10.00 |
| Substance Abuse Disorder Inpatient Services | 20.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 20.00% Coinsurance after deductible |
| Telehealth PCP | $5.00 |
| Telehealth Specialist | $50.00 |
| Transplant | 20.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 20.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 20.00% Coinsurance after deductible |