| Dental Check-Up for Children | 20.00% |
| Diabetes Care Management | $10.00 |
| Diabetes Education | 20.00% |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 20.00% |
| Acupuncture | Not covered |
| Allergy Testing | 20.00% |
| Autism Spectrum Disorders | $10.00 |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | 20.00% |
| Brain Injury | 20.00% |
| Cardiovascular Disease | 20.00% |
| Chemotherapy | $40.00 |
| Chiropractic Care | $60.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | $3,100.00 |
| Dialysis | $40.00 |
| Durable Medical Equipment | 20.00% |
| Emergency Transportation/Ambulance | $900.00 |
| Eye Glasses for Children | 20.00% |
| Habilitation Services | $70.00 |
| Hearing Aids | 20.00% |
| Home Health Care Services | No charge |
| Hospice Services | 20.00% |
| Imaging (CT/PET Scans, MRIs) | $350.00 |
| Infertility Treatment | Not covered |
| Infusion Therapy | $40.00 |
| Inherited Metabolic Disorder - PKU | 20.00% |
| Inpatient Physician and Surgical Services | 20.00% |
| Laboratory Outpatient and Professional Services | $20.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | 20.00% |
| Mammography | $40.00 |
| Nutritional Counseling | $5.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | 20.00% |
| Osteoporosis | 20.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $15.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $400.00 |
| Outpatient Rehabilitation Services | $70.00 |
| Pediatric Services Other | 20.00% |
| Post-Mastectomy Care | 20.00% |
| Prenatal and Postnatal Care | $10.00 |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | $40.00 |
| Radiation | $40.00 |
| Reconstructive Surgery | 20.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $100.00 |
| Rehabilitative Speech Therapy | $100.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | $40.00 |
| Routine Foot Care | $40.00 |
| Skilled Nursing Facility | $300.00 Copay per Stay |
| Substance Abuse Disorder Inpatient Services | $3100.00 Copay per Stay |
| Substance Abuse Disorder Outpatient Services | $110.00 |
| Transplant | 20.00% |
| Transplant Donor Coverage | 20.00% |
| Treatment for Temporomandibular Joint Disorders | 20.00% |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | See plan details |
| X-rays and Diagnostic Imaging | $125.00 |