| 2014 | FL | 86382 | HIOS | 4 | 08/30/2013 07:44:10 AM | 86382 | FL | 86382FL0020005 | 86382FL0020005-01 | Routine Eye Exam for Children | $20 | | $0 | No Charge | | 100% | Yes | | Covered | Yes | 1 | Visit(s) per Year | | | | | Yes | Yes | No | No | 102 |
| 2014 | FL | 57451 | HIOS | 4 | 10/15/2013 07:27:56 AM | 57451 | FL | 57451FL0080004 | 57451FL0080004-03 | Specialty Drugs | No Charge | | $0 | No Charge after deductible | | 100% | Yes | | Covered | | | | | | | | Yes | No | No | No | 91 |
| 2014 | WI | 91058 | HIOS | 3 | 09/02/2013 11:39:25 AM | 91058 | WI | 91058WI0080005 | 91058WI0080005-00 | Mental/Behavioral Health Outpatient Services | No Charge | | $0 | 20% Coinsurance after deductible | | 100% | Yes | | Covered | | | | | | | | Yes | No | No | No | 84 |
| 2014 | OH | 28162 | SERFF | 3 | 08/30/2013 11:49:14 AM | 28162 | OH | 28162OH0060059 | 28162OH0060059-01 | Private-Duty Nursing | No Charge | | No Charge | 30% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | | Covered | Yes | 234 | Visit(s) per Year | | | | Substantially Equal | Yes | Yes | No | No | 71 |
| 2014 | ND | 37160 | HIOS | 6 | 01/21/2014 08:29:49 AM | 37160 | ND | 37160ND2410009 | 37160ND2410009-00 | Non-Preferred Brand Drugs | No Charge | | No Charge | No Charge after deductible | | 100% | Yes | | Covered | No | | | | Weight loss drugs, drugs for hair loss, drugs for cosmetic purposes, sexual dysfunction drugs, infertility drugs, medications obtained w/out a prescription order or for any charges for the administration of legend drugs or insulin that may be self-administered unless such admin is medically appropriate and necessary. Drugs and associated expenses and devices not approved by the FDA for a particular use except as required by law (unless the practitioner certifies off-label use with a letter of medical necessity). | Subject to dispensing limit of 90 days supply. | Substantially Equal | Yes | Yes | No | Yes | 90 |
| 2014 | ID | 26002 | SERFF | 6 | 01/22/2014 11:51:12 AM | 26002 | ID | 26002ID0010011 | 26002ID0010011-01 | Well Baby Visits and Care | No Charge | | No Charge | No Charge | | 50% Coinsurance after deductible | | | Covered | No | | | | | | Additional EHB Benefit | No | No | No | No | 107 |
| 2014 | ID | 61589 | SERFF | 11 | 01/22/2014 11:51:12 AM | 61589 | ID | 61589ID1600001 | 61589ID1600001-02 | Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $0 | | $0 | 0% | | 0% | Yes | | Covered | No | | | | | | | Yes | Yes | No | No | 64 |
| 2014 | MT | 32225 | SERFF | 3 | 08/26/2013 12:29:34 PM | 32225 | MT | 32225MT0020002 | 32225MT0020002-03 | Inpatient Physician and Surgical Services | No Charge | | No Charge | 30% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | | Covered | | | | | None; Refer to the Policy Exclusions and Limitations. | | | Yes | Yes | No | No | 78 |
| 2014 | AR | 70525 | SERFF | 8 | 01/23/2014 12:49:01 PM | 70525 | AR | 70525AR0070017 | 70525AR0070017-00 | Specialty Drugs | $250 | | No Charge | No Charge | | 100% | Yes | | Covered | Yes | 30 | Days per Month | | | | Substantially Equal | No | No | No | No | 91 |
| 2014 | LA | 19636 | HIOS | 8 | 01/21/2014 08:29:49 AM | 19636 | LA | 19636LA0250002 | 19636LA0250002-00 | Routine Foot Care | | | | | | | | | Not Covered | | | | | | Except for persons who have been diagnosed with diabetes; cutting or removal of corns and calluses, nail trimming or debriding, or supportive devices of the foot. | | | | | | 99 |
| 2014 | AZ | 88925 | HIOS | 5 | 01/17/2014 09:36:20 AM | 88925 | AZ | 88925AZ0010010 | 88925AZ0010010-02 | Well Baby Visits and Care | $0 | | $0 | 0% | | 0% | | | Covered | | | | | | | Additional EHB Benefit | No | Yes | No | Yes | 107 |
| 2014 | FL | 77150 | HIOS | 9 | 03/19/2014 07:06:49 AM | 77150 | FL | 77150FL0490001 | 77150FL0490001-01 | Nutrition/Formulas | No Charge | | No Charge | 20% Coinsurance after deductible | | 50% Coinsurance after deductible | | Yes | Covered | Yes | 2500 | Dollars per Year | | | | Additional EHB Benefit | Yes | No | No | No | 134 |
| 2014 | WI | 79475 | HIOS | 10 | 11/23/2013 02:44:18 PM | 79475 | WI | 79475WI0340011 | 79475WI0340011-03 | Long-Term/Custodial Nursing Home Care | | | | | | | | | | | | | | | | | | | | | 70 |
| 2014 | WI | 47342 | HIOS | 11 | 07/25/2014 04:54:18 PM | 47342 | WI | 47342WI0060025 | 47342WI0060025-00 | Major Dental Care - Child | | | | | | | Yes | | Not Covered | | | | | | | Dental Only Plan Available | | | | | 112 |
| 2014 | NM | 75605 | SERFF | 9 | 11/27/2013 09:24:34 AM | 75605 | NM | 75605NM0370002 | 75605NM0370002-02 | Laboratory Outpatient and Professional Services | $0 | | $0 | 0% | | 0% | Yes | | Covered | | | | | | | | Yes | Yes | No | No | 108 |
| 2014 | NM | 93091 | SERFF | 9 | 03/18/2014 09:48:59 AM | 93091 | NM | 93091NM0010006 | 93091NM0010006-03 | Non-Preferred Brand Drugs | $0 | | $0 | 50% Coinsurance after deductible | | 100% | | | Covered | | | | | | | Substantially Equal | Yes | No | Yes | Yes | 90 |
| 2014 | FL | 16842 | HIOS | 6 | 01/17/2014 09:36:20 AM | 16842 | FL | 16842FL0070101 | 16842FL0070101-01 | Orthodontia - Child | $0 | | $0 | No Charge | | 100% | Yes | | Covered | No | | | | | | | No | No | No | No | 111 |
| 2014 | NC | 11512 | HIOS | 9 | 01/29/2014 08:00:05 AM | 11512 | NC | 11512NC0060028 | 11512NC0060028-06 | X-rays and Diagnostic Imaging | No Charge | | No Charge | 30% Coinsurance after deductible | | 60% Coinsurance after deductible | Yes | | Covered | | | | | | | | Yes | No | No | No | 109 |
| 2014 | MO | 32753 | HIOS | 16 | 03/19/2014 07:06:49 AM | 32753 | MO | 32753MO0770009 | 32753MO0770009-02 | Chemotherapy | $0 | | $0 | 0% | | 0% | Yes | | Covered | No | | | | | | | Yes | No | No | No | 121 |
| 2014 | AR | 70525 | SERFF | 8 | 01/23/2014 12:49:01 PM | 70525 | AR | 70525AR0070017 | 70525AR0070017-03 | Well Child Care | $0 | | No Charge | 0% | | 100% | | Yes | Covered | | | | | | | | Yes | Yes | No | No | 135 |
