| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $350.00 Copay after deductible |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 25.00% Coinsurance after deductible |
| Acupuncture | 25.00% Coinsurance after deductible |
| Allergy Testing | 25.00% Coinsurance after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | 25.00% Coinsurance after deductible |
| Chemotherapy | $500.00 Copay after deductible |
| Chiropractic Care | 25.00% Coinsurance after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 25.00% Coinsurance after deductible |
| Dental Check-Up for Children | No charge |
| Diabetes Education | 25.00% Coinsurance after deductible |
| Dialysis | $300.00 Copay after deductible |
| Durable Medical Equipment | 25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $300.00 Copay after deductible |
| Eye Glasses for Children | 25.00% Coinsurance after deductible |
| Gender Affirming Care | $350.00 Copay after deductible |
| Habilitation Services | $20.00 Copay after deductible |
| Hearing Aids | Not covered |
| Home Health Care Services | 25.00% Coinsurance after deductible |
| Hospice Services | 25.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | $50.00 Copay after deductible |
| Infertility Treatment | 25.00% Coinsurance after deductible |
| Infusion Therapy | $75.00 Copay after deductible |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $5.00 Copay after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | 25.00% Coinsurance after deductible |
| Nutritional Counseling | 25.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | 50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 25.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $20.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 25.00% Coinsurance after deductible |
| Radiation | $75.00 Copay after deductible |
| Reconstructive Surgery | $350.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $20.00 Copay after deductible |
| Rehabilitative Speech Therapy | $20.00 Copay after deductible |
| 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% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $5.00 |
| Transplant | 25.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 25.00% Coinsurance after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $5.00 Copay after deductible |