| Dental Anesthesia | 30.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Well Baby Visits and Care | No charge |
| Weight Loss Programs | Not covered |
| Major Dental Care - Child | Not covered |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 40.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | $80.00 |
| Anesthetics | No charge |
| Bariatric Surgery | 50.00% Coinsurance after deductible |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Blood and Blood Services | 25.00% |
| Cardiac Rehabilitation | No charge |
| Chemotherapy | 40.00% Coinsurance after deductible |
| Chiropractic Care | $80.00 |
| Clinical Trials | No charge |
| Congenital Anomaly, including Cleft Lip/Palate | 25.00% |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 40.00% Coinsurance after deductible |
| Diabetes Care Management | 30.00% Coinsurance after deductible |
| Diabetes Education | No charge |
| Diagnosis and Treatment of Lymphedema | 30.00% Coinsurance after deductible |
| Dialysis | 25.00% |
| Durable Medical Equipment | 50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 40.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $40.00 |
| Hearing Aids | No charge |
| Home Health Care Services | 40.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | No charge |
| Infertility Treatment | No charge |
| Infusion Therapy | 40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 25.00% |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Nutritional Counseling | No charge |
| Organ Donor Search | 30.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Orthotic Devices for Positional Plagiocephaly | 50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $0.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | No charge |
| Prosthetic Devices | 50.00% Coinsurance after deductible |
| Pulmonary Rehabilitation | 40.00% Coinsurance after deductible |
| Radiation | 40.00% Coinsurance after deductible |
| Reconstructive Surgery | No charge |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $40.00 |
| Rehabilitative Speech Therapy | $40.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $80.00 |
| Sexual Dysfunction | 40.00% Coinsurance after deductible |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Sterilization | 40.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | No charge |
| Substance Abuse Disorder Outpatient Services | $40.00 |
| Transplant | 40.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 40.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 25.00% |