| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | $600.00 Copay after deductible |
| Accidental Dental | $30.00 |
| Acupuncture | Not covered |
| Allergy Testing | $30.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Chemotherapy | $500.00 Copay after deductible |
| Chiropractic Care | $30.00 |
| Congenital Anomaly, including Cleft Lip/Palate | $500.00 Copay after deductible |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $600.00 Copay after deductible |
| Dental Anesthesia | $30.00 |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $30.00 |
| Diabetes Education | No charge |
| Dialysis | $500.00 Copay after deductible |
| Durable Medical Equipment | No charge |
| Emergency Transportation/Ambulance | 40.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $30.00 |
| Hearing Aids | Not covered |
| Home Health Care Services | No charge |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $500.00 |
| Infertility Treatment | Not covered |
| Infusion Therapy | $500.00 Copay after deductible |
| Inpatient Physician and Surgical Services | $100.00 |
| Laboratory Outpatient and Professional Services | $35.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutrition/Formulas | $30.00 |
| Nutritional Counseling | $30.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Osteoporosis | $30.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $30.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $500.00 Copay after deductible |
| Outpatient Rehabilitation Services | $30.00 |
| Prenatal and Postnatal Care | $30.00 |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | No charge |
| Radiation | $500.00 Copay after deductible |
| Reconstructive Surgery | $500.00 Copay after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 |
| Rehabilitative Speech Therapy | $30.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $30.00 |
| Skilled Nursing Facility | $500.00 Copay per Stay |
| Substance Abuse Disorder Inpatient Services | $600.00 Copay per Stay after deductible |
| Substance Abuse Disorder Outpatient Services | $15.00 |
| Transplant | $600.00 Copay after deductible |
| Treatment for Temporomandibular Joint Disorders | $30.00 |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $175.00 |