| Accidental Dental | $100.00 |
| Allergy Testing | 30.00% Coinsurance after deductible |
| Bariatric Surgery | 30.00% Coinsurance after deductible |
| Chemotherapy | 30.00% Coinsurance after deductible |
| Chiropractic Care | $50.00 |
| Delivery and All Inpatient Services for Maternity Care | 30.00% Coinsurance after deductible |
| Diabetes Education | $50.00 |
| Dialysis | 30.00% Coinsurance after deductible |
| Durable Medical Equipment | 30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 30.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $50.00 |
| Hearing Aids | 30.00% Coinsurance after deductible |
| Home Health Care Services | $50.00 |
| Hospice Respite Service | No charge |
| Imaging (CT/PET Scans, MRIs) | 30.00% Coinsurance after deductible |
| Infertility Treatment | $50.00 |
| Infusion Therapy | 30.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 30.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 30.00% Coinsurance after deductible |
| Nutritional Counseling | $50.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $50.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 30.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $50.00 |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | $50.00 |
| Prosthetic Devices | 30.00% Coinsurance after deductible |
| Radiation | 30.00% Coinsurance after deductible |
| Reconstructive Surgery | 30.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $50.00 |
| Rehabilitative Speech Therapy | $50.00 |
| Routine Eye Exam for Children | No charge |
| Skilled Nursing Facility | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 30.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | 30.00% Coinsurance after deductible |
| Transplant | 30.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | $50.00 |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 30.00% Coinsurance after deductible |