| Substance Abuse Disorder Outpatient Services | $5.00 |
| Abortion for Which Public Funding is Prohibited | No charge |
| Acupuncture | $25.00 |
| Allergy Testing | $25.00 |
| Applied Behavior Analysis Based Therapies | $5.00 |
| Autism Spectrum Disorders - Assessment and Evaluation Services | $5.00 |
| Bariatric Surgery | 10.00% Coinsurance after deductible |
| Basic Dental Care - Child | 50.00% Coinsurance after deductible |
| Chemotherapy | 10.00% Coinsurance after deductible |
| Chiropractic Care | $25.00 |
| Delivery and All Inpatient Services for Maternity Care | 10.00% Coinsurance after deductible |
| Dental Check-Up for Children | No Charge after deductible |
| Diabetes Education | $5.00 |
| Diabetic Supplies | 20.00% |
| Dialysis | 10.00% Coinsurance after deductible |
| Durable Medical Equipment | 10.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 10.00% Coinsurance after deductible |
| Eye Glasses for Children | 50.00% |
| Gender Affirming Care | 10.00% Coinsurance after deductible |
| Habilitation Services | $5.00 |
| Hearing Aids | 10.00% Coinsurance after deductible |
| Home Health Care Services | 10.00% Coinsurance after deductible |
| Hospice Services | No charge |
| Imaging (CT/PET Scans, MRIs) | $25.00 |
| Infertility Treatment | 10.00% Coinsurance after deductible |
| Infusion Therapy | 10.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 10.00% Coinsurance after deductible |
| Inpatient Rehabilitation | 10.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $10.00 |
| Major Dental Care - Child | 50.00% Coinsurance after deductible |
| Nutritional Counseling | $5.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $25.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 10.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $5.00 |
| Prenatal and Postnatal Care | 10.00% Coinsurance after deductible |
| Private-Duty Nursing | 10.00% Coinsurance after deductible |
| Prosthetic Devices | 10.00% Coinsurance after deductible |
| Prosthetics: Legs and Arms | 10.00% |
| Prosthetics: Recreational | 10.00% |
| Radiation | 10.00% Coinsurance after deductible |
| Reconstructive Surgery | 10.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $5.00 |
| Rehabilitative Occupational Therapy | $5.00 |
| Rehabilitative Physical Therapy | $5.00 |
| Rehabilitative Speech Therapy | $5.00 |
| Routine Eye Exam for Children | $5.00 |
| Skilled Nursing Facility | 10.00% Coinsurance after deductible |
| Standalone Laboratory | $10.00 |
| Substance Abuse Disorder Inpatient Services | 10.00% Coinsurance after deductible |
| Telehealth PCP | No charge |
| Telehealth Specialist | No charge |
| Transplant | 10.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 10.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 10.00% Coinsurance after deductible |