- Doctor services: $5

- Preventive care: $0

- Hospital inpatient
  services: $0

- Laboratory tests
  and X-rays: $0

- Vision services: $5

- Dental services: $0-$15

- Prescription drugs: $5

- Emergency health care: $5

- Emergency medical transportation: $0

- Durable medical equipment and medical supplies: $0

- Mental health services (Inpatient Care): $0

- Alcohol and drug abuse services: $5

- Physical, occupational, speech therapy:
  * Outpatient $5
  * Inpatient: $0