| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | 35.00% Coinsurance after deductible |
| Chemotherapy | 35.00% Coinsurance after deductible |
| Chiropractic Care | 35.00% Coinsurance after deductible |
| Cosmetic Surgery | 35.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | 35.00% Coinsurance after deductible |
| Dental Anesthesia | 35.00% Coinsurance after deductible |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | 35.00% Coinsurance after deductible |
| Durable Medical Equipment | 35.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 35.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 35.00% Coinsurance after deductible |
| Habilitation Services | 35.00% Coinsurance after deductible |
| Hearing Aids | 35.00% |
| Hearing Exams | $110.00 Copay after deductible |
| Home Health Care Services | 35.00% Coinsurance after deductible |
| Hospice Services | 35.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 35.00% Coinsurance after deductible |
| Infertility Treatment | 35.00% Coinsurance after deductible |
| Infusion Therapy | 35.00% Coinsurance after deductible |
| Inherited Metabolic Disorder - PKU | 35.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 35.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 35.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | 35.00% Coinsurance after deductible |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $50.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 35.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 35.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 35.00% Coinsurance after deductible |
| Radiation | 35.00% Coinsurance after deductible |
| Reconstructive Surgery | 35.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 35.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy | 35.00% Coinsurance after deductible |
| Routine Eye Exam for Children | $30.00 |
| Routine Foot Care | $50.00 |
| Skilled Nursing Facility | 35.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 35.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $75.00 |
| Transplant | 35.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 35.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 35.00% Coinsurance after deductible |