| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | $20.00 |
| Acupuncture | $20.00 |
| Allergy Testing | 10.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies | 10.00% Coinsurance after deductible |
| Bariatric Surgery | 10.00% Coinsurance after deductible |
| Basic Dental Care - Adult | Not covered |
| Basic Dental Care - Child | Not covered |
| Bone Marrow Transplant | 10.00% Coinsurance after deductible |
| Chemotherapy | 10.00% Coinsurance after deductible |
| Chiropractic Care | $20.00 |
| Convenience Care Clinic | $20.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 10.00% Coinsurance after deductible |
| Dental Anesthesia | 10.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Care Management | $20.00 |
| Diabetes Education | $40.00 |
| Dialysis | 10.00% Coinsurance after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Early Intervention Services | No charge |
| Emergency Transportation/Ambulance | 10.00% Coinsurance after deductible |
| Eye Glasses for Children | 50.00% |
| Gender Affirming Care | 10.00% Coinsurance after deductible |
| Habilitation Services | $40.00 Copay after deductible |
| Hearing Aids | 50.00% |
| Home Health Care Services | 10.00% Coinsurance after deductible |
| Hospice Services | 10.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 10.00% Coinsurance after deductible |
| Infertility Treatment | Not covered |
| Infusion Therapy | 10.00% Coinsurance after deductible |
| Inherited Metabolic Disorders - PKU | 10.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 10.00% Coinsurance after deductible |
| Inpatient Rehabilitation Services | 10.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 10.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Low Protein Foods | 10.00% Coinsurance after deductible |
| Major Dental Care - Adult | Not covered |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $20.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $40.00 Copay after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 10.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $40.00 Copay after deductible |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | Not covered |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | 10.00% Coinsurance after deductible |
| Reconstructive Surgery | 10.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $40.00 Copay after deductible |
| Rehabilitative Speech Therapy | $40.00 Copay after deductible |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | $20.00 |
| Routine Eye Exam for Children | $20.00 |
| Routine Foot Care | $40.00 |
| Skilled Nursing Facility | 10.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 10.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $20.00 |
| Transplant | 10.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 10.00% Coinsurance after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| Wigs | 20.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 10.00% Coinsurance after deductible |