| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $100.00 |
| Allergy Testing | 60.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies | 60.00% Coinsurance after deductible |
| Autism Spectrum Disorders - Assessment and Evaluation Services | 60.00% Coinsurance after deductible |
| Bariatric Surgery | 60.00% Coinsurance after deductible |
| Chemotherapy | 60.00% Coinsurance after deductible |
| Chiropractic Care | $100.00 |
| Delivery and All Inpatient Services for Maternity Care | 60.00% Coinsurance after deductible |
| Diabetes Education | No charge |
| Diabetic Supplies | 60.00% Coinsurance after deductible |
| Dialysis | 60.00% Coinsurance after deductible |
| Durable Medical Equipment | 60.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 60.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 60.00% Coinsurance after deductible |
| Habilitation Services | $100.00 |
| Hearing Aids | 60.00% Coinsurance after deductible |
| Home Health Care Services | 60.00% Coinsurance after deductible |
| Hospice Services | 60.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 60.00% Coinsurance after deductible |
| Infertility Treatment | 60.00% Coinsurance after deductible |
| Infusion Therapy | 60.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 60.00% Coinsurance after deductible |
| Inpatient Rehabilitation | $100.00 |
| Laboratory Outpatient and Professional Services | $100.00 |
| Nutritional Counseling | 60.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $50.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 60.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $100.00 |
| Prenatal and Postnatal Care | $50.00 |
| Private-Duty Nursing | 60.00% Coinsurance after deductible |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Prosthetics: Legs and Arms | 20.00% |
| Prosthetics: Recreational | 20.00% Coinsurance after deductible |
| Radiation | 60.00% Coinsurance after deductible |
| Reconstructive Surgery | 60.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $100.00 |
| Rehabilitative Occupational Therapy | $100.00 |
| Rehabilitative Physical Therapy | $100.00 |
| Rehabilitative Speech Therapy | $100.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | 60.00% Coinsurance after deductible |
| Standalone Laboratory | $50.00 |
| Substance Abuse Disorder Inpatient Services | 60.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 60.00% Coinsurance after deductible |
| Telehealth PCP | $50.00 |
| Telehealth Specialist | $100.00 |
| Transplant | 60.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 60.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 60.00% Coinsurance after deductible |