| Abortion for Which Public Funding is Prohibited | $250.00 |
| Accidental Dental | $250.00 |
| Active & Fit | $200.00 |
| Acupuncture | Not covered |
| Allergy Testing | $20.00 |
| Bariatric Surgery | $400.00 |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | 20.00% |
| Chiropractic Care | Not covered |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $400.00 |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | $20.00 |
| Dialysis | 20.00% |
| Durable Medical Equipment | 20.00% |
| Emergency Transportation/Ambulance | $250.00 |
| Eye Glasses for Children | No charge |
| Habilitation Services | $20.00 |
| Hearing Aids | 60.00% |
| Home Health Care Services | No charge |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $250.00 |
| Infertility Treatment | $20.00 + 20.00% |
| Infusion Therapy | 20.00% |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $60.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | No charge |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $20.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $250.00 |
| Outpatient Rehabilitation Services | $20.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | $400.00 |
| Radiation | 20.00% |
| Reconstructive Surgery | $400.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $20.00 |
| Rehabilitative Speech Therapy | $20.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | $20.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | $250.00 Copay per Stay |
| Substance Abuse Disorder Inpatient Services | $400.00 Copay per Stay |
| Substance Abuse Disorder Outpatient Services | $20.00 |
| Transplant | $400.00 |
| Treatment for Temporomandibular Joint Disorders | $400.00 |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $60.00 |