| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | $35.00 |
| Acupuncture | No Charge after deductible |
| Allergy Testing | No Charge after deductible |
| Bariatric Surgery | No Charge after deductible |
| Basic Dental Care - Child | No Charge after deductible |
| Bone Marrow Transplants for Treatment of Breast Cancer | No Charge after deductible |
| Cardiac Rehabilitation | No Charge after deductible |
| Chemotherapy | No Charge after deductible |
| Childbirth Classes | No charge |
| Chiropractic Care | No Charge after deductible |
| Clinical Trials | No Charge after deductible |
| Congenital Anomaly, including Cleft Lip/Palate | No Charge after deductible |
| Contraceptive Services | No charge |
| Delivery and All Inpatient Services for Maternity Care | No Charge after deductible |
| Dental Check-Up for Children | No Charge after deductible |
| Diabetes Care Management | $35.00 |
| Diabetes Education | No Charge after deductible |
| Dialysis | No Charge after deductible |
| Durable Medical Equipment | No Charge after deductible |
| Early Intervention Services | No charge |
| Emergency Transportation/Ambulance | No Charge after deductible |
| Eye Glasses for Children | No Charge after deductible |
| Fitness Club Reimbursement | No charge |
| Gender Affirming Care | No Charge after deductible |
| Habilitation Services | No Charge after deductible |
| Hearing Aids | No Charge after deductible |
| Home Health Care Services | No Charge after deductible |
| Hormone Replacement Therapy (HRT) | No Charge after deductible |
| Hospice Services | No Charge after deductible |
| Human Leukocyte Antigen Testing | No Charge after deductible |
| Hypodermic Syringes or Needles | No Charge after deductible |
| Imaging (CT/PET Scans, MRIs) | No Charge after deductible |
| Infertility Treatment | No Charge after deductible |
| Infusion Therapy | No Charge after deductible |
| Inherited Metabolic Disorders - PKU | No Charge after deductible |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Inpatient Rehabilitation Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | No Charge after deductible |
| Low Protein Foods | No Charge after deductible |
| Major Dental Care - Child | No Charge after deductible |
| Minor Dental Care - Child | No Charge after deductible |
| Nutrition/Formulas | No Charge after deductible |
| Nutritional Counseling | $35.00 |
| Orthodontia - Child | No Charge after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No Charge after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | No Charge after deductible |
| Outpatient Rehabilitation Services | No Charge after deductible |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | No Charge after deductible |
| Radiation | No Charge after deductible |
| Reconstructive Surgery | No Charge after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | No Charge after deductible |
| Rehabilitative Speech Therapy | No Charge after deductible |
| Retail Health Clinics | No Charge after deductible |
| Routine Eye Exam (Adult) | No Charge after deductible |
| 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 | No Charge after deductible |
| Treatment for Temporomandibular Joint Disorders | No Charge after deductible |
| Weight Loss Programs | No charge |
| Well Baby Visits and Care | No charge |
| Wigs | No Charge after deductible |
| X-rays and Diagnostic Imaging | No Charge after deductible |