| Durable Medical Equipment | 40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 40.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $30.00 |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | 40.00% Coinsurance after deductible |
| Infusion Therapy | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $60.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $30.00 |
| Diabetes Education | No charge |
| Dialysis | $60.00 |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | $30.00 |
| Delivery and All Inpatient Services for Maternity Care | 40.00% Coinsurance after deductible |
| Accidental Dental | 40.00% Coinsurance after deductible |
| Allergy Testing | $30.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $30.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 40.00% Coinsurance after deductible |
| Radiation | 40.00% Coinsurance after deductible |
| Reconstructive Surgery | 40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 |
| Rehabilitative Speech Therapy | $30.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $30.00 |
| Transplant | 40.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $95.00 |