| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $25.00 |
| Allergy Testing | 25.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies | 25.00% Coinsurance after deductible |
| Autism Spectrum Disorders - Assessment and Evaluation Services | $75.00 |
| Bariatric Surgery | 25.00% Coinsurance after deductible |
| Basic Dental Care - Child | No charge |
| Chemotherapy | 25.00% Coinsurance after deductible |
| Chiropractic Care | $25.00 |
| Delivery and All Inpatient Services for Maternity Care | 25.00% Coinsurance after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | $70.00 |
| Diabetic Supplies | 25.00% Coinsurance after deductible |
| Dialysis | 25.00% Coinsurance after deductible |
| Durable Medical Equipment | 25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $500.00 Copay after deductible |
| Eye Glasses for Children | 25.00% Coinsurance after deductible |
| Gender Affirming Care | 25.00% Coinsurance after deductible |
| Habilitation Services | $75.00 |
| Hearing Aids | 25.00% Coinsurance after deductible |
| Home Health Care Services | 25.00% Coinsurance after deductible |
| Hospice Services | 25.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 25.00% Coinsurance after deductible |
| Infertility Treatment | 25.00% Coinsurance after deductible |
| Infusion Therapy | 25.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 25.00% Coinsurance after deductible |
| Inpatient Rehabilitation | 25.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $20.00 |
| Major Dental Care - Child | No charge |
| Nutritional Counseling | 25.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $25.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 25.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $75.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 25.00% Coinsurance after deductible |
| Prosthetic Devices | 25.00% Coinsurance after deductible |
| Prosthetics: Legs and Arms | 20.00% |
| Prosthetics: Recreational | 25.00% Coinsurance after deductible |
| Radiation | 25.00% Coinsurance after deductible |
| Reconstructive Surgery | 25.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $75.00 |
| Rehabilitative Occupational Therapy | $75.00 |
| Rehabilitative Physical Therapy | $75.00 |
| Rehabilitative Speech Therapy | $75.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | 25.00% Coinsurance after deductible |
| Standalone Laboratory | $20.00 |
| Substance Abuse Disorder Inpatient Services | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 25.00% Coinsurance after deductible |
| Telehealth PCP | $25.00 |
| Telehealth Specialist | $75.00 |
| Transplant | 25.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 25.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 25.00% Coinsurance after deductible |