| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | 45.00% Coinsurance after deductible |
| Acupuncture | 45.00% Coinsurance after deductible |
| Allergy Testing | 45.00% Coinsurance after deductible |
| Chemotherapy | $500.00 Copay after deductible |
| Chiropractic Care | 45.00% Coinsurance after deductible |
| Cosmetic Surgery | $300.00 Copay after deductible |
| Delivery and All Inpatient Services for Maternity Care | $1500.00 Copay after deductible |
| Dental Anesthesia | 45.00% Coinsurance after deductible |
| Diabetes Care Management | 45.00% Coinsurance after deductible |
| Diabetes Education | 45.00% Coinsurance after deductible |
| Dialysis | $300.00 Copay after deductible |
| Durable Medical Equipment | 45.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $500.00 Copay after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | $300.00 Copay after deductible |
| Habilitation Services | $35.00 Copay after deductible |
| Hearing Aids | 45.00% |
| Hearing Exams | $10.00 |
| Home Health Care Services | 45.00% Coinsurance after deductible |
| Hospice Services | 45.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | $300.00 Copay after deductible |
| Infertility Treatment | 45.00% Coinsurance after deductible |
| Infusion Therapy | $100.00 Copay after deductible |
| Inherited Metabolic Disorder - PKU | 45.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $10.00 |
| Nutritional Counseling | 45.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | 45.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $300.00 Copay after deductible |
| Outpatient Rehabilitation Services | $35.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 45.00% Coinsurance after deductible |
| Radiation | $150.00 Copay after deductible |
| Reconstructive Surgery | $300.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $35.00 Copay after deductible |
| Rehabilitative Speech Therapy | $35.00 Copay after deductible |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $40.00 |
| Skilled Nursing Facility | $1500.00 Copay per Day after deductible |
| Substance Abuse Disorder Inpatient Services | $1500.00 Copay per Day after deductible |
| Substance Abuse Disorder Outpatient Services | $35.00 |
| Transplant | $1500.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | 45.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $65.00 Copay after deductible |