| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 25.00% |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $10.00 |
| Acupuncture | Not covered |
| Allergy Testing | 25.00% |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | $50.00 + 25.00% |
| Chemotherapy | 25.00% |
| Chiropractic Care | 25.00% |
| CLINICAL_TRIALS | $50.00 + 25.00% |
| Cosmetic Surgery | $50.00 + 25.00% |
| Delivery and All Inpatient Services for Maternity Care | $50.00 + 25.00% |
| Dental Check-Up for Children | Not covered |
| Diabetes Care | $10.00 |
| Diabetes Education | $10.00 |
| Dialysis | 25.00% |
| Durable Medical Equipment | 25.00% |
| Emergency Transportation/Ambulance | 25.00% |
| Eye Glasses for Children | No charge |
| Habilitation Services | 25.00% |
| Hearing Aids | 25.00% |
| HEART_TRANSPLANT | $50.00 + 25.00% |
| Home Health Care Services | 25.00% |
| Hospice Services | 25.00% |
| Imaging (CT/PET Scans, MRIs) | $150.00 + 25.00% |
| Infertility Treatment | 25.00% |
| Infusion Therapy | 25.00% |
| Inpatient Physician and Surgical Services | 25.00% |
| Laboratory Outpatient and Professional Services | 25.00% |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | 25.00% |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $5.00 |
| Outpatient Rehabilitation Services | 25.00% |
| Prenatal and Postnatal Care | 25.00% |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 25.00% |
| Radiation | 25.00% |
| Reconstructive Surgery | $50.00 + 25.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 25.00% |
| Rehabilitative Speech Therapy | 25.00% |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 25.00% |
| Substance Abuse Disorder Inpatient Services | $50.00 Copay per Stay + 25.00% |
| Substance Abuse Disorder Outpatient Services | 25.00% |
| Transplant | $50.00 + 25.00% |
| Treatment for Temporomandibular Joint Disorders | 25.00% |
| Weight Loss Programs | $10.00 |
| Well Baby Visits and Care | No charge |
| Well Child Care | No charge |
| X-rays and Diagnostic Imaging | 25.00% |