| Home Health Care Services | No Charge after deductible |
| Hospice Services | No Charge after deductible |
| Imaging (CT/PET Scans, MRIs) | No Charge after deductible |
| Infusion Therapy | No Charge after deductible |
| Accidental Dental | No Charge after deductible |
| Allergy Testing | $125.00 |
| Chemotherapy | No Charge after deductible |
| Chiropractic Care | No Charge after deductible |
| Delivery and All Inpatient Services for Maternity Care | No Charge after deductible |
| Diabetes Education | No charge |
| 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 |
| Inpatient Physician and Surgical Services | No Charge after deductible |
| Laboratory Outpatient and Professional Services | $75.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $45.00 |
| 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 after deductible |
| 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 |
| Routine Eye Exam for Children | $125.00 |
| Skilled Nursing Facility | No Charge after deductible |
| Substance Abuse Disorder Inpatient Services | No Charge after deductible |
| Substance Abuse Disorder Outpatient Services | $45.00 |
| Transplant | No Charge after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $75.00 |