| 2014 | AZ | 88925 | HIOS | 5 | 01/17/2014 09:36:20 AM | 88925 | AZ | 88925AZ0010026 | 88925AZ0010026-03 | Dialysis | | | | | | | | | Not Covered | | | | | | | | | | | | 119 |
| 2014 | FL | 56503 | HIOS | 6 | 03/19/2014 07:06:49 AM | 56503 | FL | 56503FL1170003 | 56503FL1170003-04 | Private-Duty Nursing | | | | | | | | | | | | | | | | | | | | | 71 |
| 2014 | AZ | 53901 | HIOS | 7 | 01/16/2014 07:24:04 AM | 53901 | AZ | 53901AZ0580001 | 53901AZ0580001-01 | Weight Loss Programs | | | | | | | | | | | | | | | | | | | | | 101 |
| 2014 | LA | 42544 | HIOS | 5 | 01/17/2014 09:36:20 AM | 42544 | LA | 42544LA0010001 | 42544LA0010001-00 | Orthodontia - Adult | | | | | | | | | | | | | | | | | | | | | 114 |
| 2014 | VA | 16064 | SERFF | 6 | 06/23/2014 03:22:56 PM | 16064 | VA | 16064VA1220001 | 16064VA1220001-00 | Orthodontia - Adult | | | | | | | | | | | | | | | | | | | | | 114 |
| 2014 | PA | 55957 | HIOS | 5 | 11/26/2013 01:14:08 PM | 55957 | PA | 55957PA0160001 | 55957PA0160001-01 | Bariatric Surgery | | | | | | | | | Not Covered | | | | | | | | | | | | 79 |
| 2014 | TN | 14002 | HIOS | 7 | 01/29/2014 08:00:05 AM | 14002 | TN | 14002TN0330018 | 14002TN0330018-06 | Nutritional Counseling | | | | | | | | | | | | | | | | | | | | | 127 |
| 2014 | PA | 31609 | OPM | 3 | 01/24/2014 09:49:15 AM | 31609 | PA | 31609PA0140002 | 31609PA0140002-02 | Hospice Services | $0 | | $0 | 0% | | 0% | Yes | | Covered | | | | | | | | Yes | No | No | No | 66 |
| 2014 | AZ | 60761 | HIOS | 5 | 11/23/2013 02:44:18 PM | 60761 | AZ | 60761AZ0100001 | 60761AZ0100001-00 | Naturopathy | | | | | | | | | Not Covered | | | | | | | Above EHB | No | No | Yes | Yes | 136 |
| 2014 | AZ | 88925 | HIOS | 5 | 01/17/2014 09:36:20 AM | 88925 | AZ | 88925AZ0010007 | 88925AZ0010007-01 | Private-Duty Nursing | | | | | | | | | Not Covered | | | | | | | | | | | | 71 |
| 2014 | FL | 35783 | HIOS | 5 | 03/19/2014 07:06:49 AM | 35783 | FL | 35783FL1160018 | 35783FL1160018-00 | Private-Duty Nursing | | | | | | | | | Not Covered | | | | | | | | | | | | 71 |
| 2014 | TN | 99248 | HIOS | 14 | 10/15/2013 07:27:56 AM | 99248 | TN | 99248TN0020002 | 99248TN0020002-02 | Emergency Transportation/Ambulance | $0 | | $0 | 0% | | 0% | Yes | | Covered | | | | | | | | Yes | Yes | No | No | 76 |
| 2014 | IN | 85320 | HIOS | 7 | 01/21/2014 08:29:49 AM | 85320 | IN | 85320IN0010065 | 85320IN0010065-02 | Preferred Brand Drugs | $0 | $0 | $0 | 0% | 0% | 100% | Yes | | Covered | No | | | | Over the counter drugs with over the counter equivalents; drugs for weight loss; stop smoking aids; nutritional and/or dietary supplements; drugs for the treatment of sexual or erectile dysfunction or inadequacies; fertility drugs; human growth hormone for children born small for gestational age; treatment of onychomycosis. | | | Yes | Yes | No | No | 89 |
| 2014 | TX | 55409 | HIOS | 12 | 10/15/2013 07:27:56 AM | 55409 | TX | 55409TX0020011 | 55409TX0020011-01 | Inpatient Hospital Services (e.g., Hospital Stay) | $1000 Copay per Day | | $0 Copay per Day | No Charge | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | | | No | No | No | No | 77 |
| 2014 | OK | 76668 | HIOS | 6 | 11/26/2013 01:14:08 PM | 76668 | OK | 76668OK0030004 | 76668OK0030004-02 | Congenital Anomaly, including Cleft Lip/Palate | $0 | | $0 | 0% | | 0% | | Yes | Covered | No | | | | | | Additional EHB Benefit | Yes | Yes | No | No | 132 |
| 2014 | UT | 68781 | SERFF | 6 | 03/18/2014 09:48:59 AM | 68781 | UT | 68781UT0010012 | 68781UT0010012-04 | Generic Drugs | $10 | | $10 | No Charge | | No Charge | Yes | | Covered | No | | | | | | | No | No | No | No | 88 |
| 2014 | FL | 86382 | HIOS | 4 | 08/30/2013 07:44:10 AM | 86382 | FL | 86382FL0030012 | 86382FL0030012-01 | Acupuncture | | | | | | | | | Not Covered | | | | | | | | | | | | 100 |
| 2014 | MO | 32753 | HIOS | 16 | 03/19/2014 07:06:49 AM | 32753 | MO | 32753MO0770007 | 32753MO0770007-04 | Hospice Services | No Charge | | No Charge | 0% Coinsurance after deductible | | 30% Coinsurance after deductible | Yes | | Covered | No | | | | | | | Yes | No | No | No | 66 |
| 2014 | AZ | 53901 | HIOS | 7 | 01/16/2014 07:24:04 AM | 53901 | AZ | 53901AZ0550003 | 53901AZ0550003-04 | Infusion Therapy | No Charge | | No Charge | 20% Coinsurance after deductible | | 50% Coinsurance after deductible | | | Covered | | | | | | | Additional EHB Benefit | Yes | No | No | No | 125 |
| 2014 | TX | 33602 | HIOS | 8 | 11/23/2013 02:44:18 PM | 33602 | TX | 33602TX0420004 | 33602TX0420004-00 | Substance Abuse Disorder Inpatient Services | $250 | | $350 | 20% Coinsurance after deductible | | 40% Coinsurance after deductible | Yes | | Covered | | | | | | | Substantially Equal | Yes | Yes | No | No | 87 |
