| Hospital Coverage | Covered in full | Base Hospital Coverage: Up to 100% of allowed charge |
| Skilled Nursing | Not covered | Not covered |
| Maternity and Routine Nursery Care | Covered in full | Base Hospital Coverage |
| Hospice Care | Covered in full - 210 days per lifetime | Base Hospital Coverage |
| Ambulatory Surgery | Covered in full | Base Hospital Coverage |
| Home Health Care | Covered in full - 40 visits per year | Base Hospital Coverage |
| Home and Office Visits | Not Covered | Not Covered |
| Annual Physical Check-up | Not Covered | Not Covered |
| OB/GYN preventive 2 visits | Not Covered | Not Covered |
| Allergy Care | Not Covered | Not Covered |
| Chiropractic Care | Not Covered | Not Covered |
| Physical Therapy, Osteopathic Manipulation, Occupational Therapy | Not Covered | Not Covered |
| Routine Podiatric Care | Not Covered | Not Covered |
| Speech Therapy | Not Covered | Not Covered |
| Well-baby and Well-child Care up to Age 19 | Not Covered | Not Covered |
| Diagnostic Lab Tests and Radiology Procedures | Outpatient Referred Ambulatory Care: laboratory tests,PT, diagnostic X-rays and radiation therapy and chemotherapy: Covered in full | Outpatient Referred Ambulatory Care: Base Hospital Coverage |
| ER Professional Charge | Not Covered | Not Covered |
| Emergency Facility Charge (Waived if Admitted) | $50 copay | $50 copay |
| Inpatient Mental Health | Covered in full - 30 days per year | Not Covered |
| Inpatient Chemical Dependency Treatment (Detoxification) | Covered in full - 5 days per year | Not Covered |
| Chemical Dependency Treatment (Rehabilitation) | Not Covered | Not Covered |
| Outpatient Chemical Dependency Treatment | Covered in full - 60 visits per year | Base Hospital Coverage |
| Outpatient Mental Health | Not Covered | Not Covered |
