| Cosmetic Surgery | Not covered |
| Nutritional Counseling | $5.00 |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | No Charge after deductible |
| Acupuncture | Not covered |
| Allergy Testing | No Charge after deductible |
| Autism Spectrum Disorders | No Charge after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | No Charge after deductible |
| Brain Injury | No Charge after deductible |
| Cardiovascular Disease | No Charge after deductible |
| Chemotherapy | No Charge after deductible |
| Chiropractic Care | No Charge after deductible |
| Delivery and All Inpatient Services for Maternity Care | No Charge after deductible |
| Dental Check-Up for Children | No Charge after deductible |
| Diabetes Care Management | No Charge after deductible |
| Diabetes Education | No Charge after deductible |
| Dialysis | No Charge after deductible |
| Durable Medical Equipment | No Charge after deductible |
| Emergency Transportation/Ambulance | No Charge after deductible |
| Eye Glasses for Children | No Charge after deductible |
| Habilitation Services | No Charge after deductible |
| Hearing Aids | No Charge after deductible |
| Home Health Care Services | No charge |
| Hospice Services | No Charge after deductible |
| Imaging (CT/PET Scans, MRIs) | No Charge after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | No Charge after deductible |
| Inherited Metabolic Disorder - PKU | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | No Charge after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | No Charge after deductible |
| Mammography | $250.00 Copay after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | No Charge after deductible |
| Osteoporosis | No Charge after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $25.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | No Charge after deductible |
| Outpatient Rehabilitation Services | No Charge after deductible |
| Pediatric Services Other | No Charge after deductible |
| Post-Mastectomy Care | No Charge after deductible |
| Prenatal and Postnatal Care | No Charge after deductible |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | No Charge after deductible |
| Radiation | No Charge after deductible |
| Reconstructive Surgery | 20.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | No Charge after deductible |
| Rehabilitative Speech Therapy | No Charge after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No Charge after deductible |
| Routine Foot Care | No Charge after deductible |
| Skilled Nursing Facility | No Charge after deductible |
| Substance Abuse Disorder Inpatient Services | No Charge after deductible |
| Substance Abuse Disorder Outpatient Services | No Charge after deductible |
| Transplant | 20.00% |
| Transplant Donor Coverage | No Charge after deductible |
| Treatment for Temporomandibular Joint Disorders | No Charge after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | See plan details |
| X-rays and Diagnostic Imaging | No Charge after deductible |