| Gastric Electrical Stimulation | $10.00 |
| Well Baby Visits and Care | No charge |
| Well Child Care | No charge |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $100.00 Copay after deductible |
| Acquired Brain Injury | $250.00 Copay after deductible |
| Acupuncture | Not covered |
| Allergy Testing | $20.00 |
| Applied Behavior Analysis Based Therapies | $100.00 Copay after deductible |
| Bariatric Surgery | $250.00 Copay after deductible |
| Basic Dental Care - Adult | 50.00% |
| Basic Dental Care - Child | Not covered |
| Biomarke | $10.00 |
| Cardiac Rehabilitation | $10.00 |
| Chemotherapy | $10.00 |
| Chiropractic Care | $20.00 |
| Cochlear Implants | No charge |
| Community Health Worke | $10.00 |
| Cosmetic Surgery | Not covered |
| Craniofacial Surgery | $250.00 Copay after deductible |
| Delivery and All Inpatient Services for Maternity Care | $250.00 Copay after deductible |
| Dental Anesthesia | $100.00 Copay after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $20.00 |
| Diabetes Education | $20.00 |
| Dialysis | $100.00 Copay after deductible |
| Doulas | $10.00 |
| Durable Medical Equipment | $10.00 |
| Emergency Transportation/Ambulance | $250.00 Copay after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $10.00 |
| Hearing Aids | No charge |
| Home Health Care Services | $10.00 |
| Hospice Services | $35.00 Copay after deductible |
| Imaging (CT/PET Scans, MRIs) | $50.00 |
| Infertility Treatment | $100.00 Copay after deductible |
| Infusion Therapy | $100.00 Copay after deductible |
| Inherited Metabolic Disorder - PKU | $10.00 |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $10.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | 50.00% |
| Major Dental Care - Child | Not covered |
| Weight Loss Programs | Not covered |
| Nutritional Counseling | $20.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $10.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $100.00 Copay after deductible |
| Outpatient Rehabilitation Services | $10.00 |
| PANS-PANDA | $100.00 Copay after deductible |
| Prenatal and Postnatal Care | $10.00 |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | $10.00 |
| Radiation | $100.00 Copay after deductible |
| Reconstructive Surgery | $250.00 Copay after deductible |
| Weight Loss Treatment | $250.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $10.00 |
| Rehabilitative Speech Therapy | $10.00 |
| Restorative Reproductive Treatment | $100.00 Copay after deductible |
| Routine Dental Services (Adult) | No charge |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $20.00 |
| Skilled Nursing Facility | $35.00 Copay per Day after deductible |
| Substance Abuse Disorder Inpatient Services | $250.00 Copay per Day after deductible |
| Substance Abuse Disorder Outpatient Services | $10.00 |
| Transplant | $250.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | $100.00 Copay after deductible |
| X-rays and Diagnostic Imaging | $20.00 |