| 2014 | OH | 77552 | SERFF | 6 | 10/15/2013 10:04:03 AM | 77552 | OH | 77552OH0010029 | 77552OH0010029-02 | Well Baby Visits and Care | $0 | | $0 | 0% | | 0% | | | Covered | No | | | | | | Additional EHB Benefit | No | No | No | No | 107 |
| 2014 | AR | 60559 | SERFF | 10 | 01/23/2014 12:49:01 PM | 60559 | AR | 60559AR0020001 | 60559AR0020001-00 | Orthodontia - Adult | | | | | | | | | | | | | | | | | | | | | 114 |
| 2014 | AR | 70525 | SERFF | 8 | 01/23/2014 12:49:01 PM | 70525 | AR | 70525AR0070039 | 70525AR0070039-06 | Habilitation Services | $4 | | No Charge after deductible | No Charge | | 50% Coinsurance after deductible | | | Covered | | | | | | Physical Therapy, Speech Therapy, and Occupational Therapy are limited to a combined maximum of 30 visits per Calendar Year. Medically Necessary developmental services are limited to 180 visits per Policy year. | Substantially Equal | No | No | No | No | 93 |
| 2014 | PA | 52899 | HIOS | 11 | 03/19/2014 07:06:49 AM | 52899 | PA | 52899PA0030047 | 52899PA0030047-06 | Inpatient Physician and Surgical Services | No Charge | | No Charge | 10% Coinsurance after deductible | | 100% | Yes | | Covered | | | | | | | | Yes | No | No | No | 78 |
| 2014 | FL | 56503 | HIOS | 6 | 03/19/2014 07:06:49 AM | 56503 | FL | 56503FL1160001 | 56503FL1160001-01 | Transplant | No Charge | | $0 | 20% Coinsurance after deductible | | 100% | Yes | | Covered | | | | | | Pre-Certification/Pre-Authorization of coverage required. Out of pocket information refers to outpatient physician services only. Please refer to other benefit information for further details. | Substantially Equal | Yes | Yes | No | No | 117 |
| 2014 | FL | 35783 | HIOS | 5 | 03/19/2014 07:06:49 AM | 35783 | FL | 35783FL1150006 | 35783FL1150006-02 | Dental Check-Up for Children | | | | | | | Yes | | Not Covered | | | | | | | Dental Only Plan Available | | | | | 104 |
| 2014 | IN | 50816 | HIOS | 9 | 11/26/2013 01:14:08 PM | 50816 | IN | 50816IN0110036 | 50816IN0110036-00 | Dialysis | No Charge | | $0 | 20% Coinsurance after deductible | | 100% | Yes | | Covered | | | | | | | | Yes | Yes | No | Yes | 119 |
| 2014 | UT | 68781 | SERFF | 6 | 03/18/2014 09:48:59 AM | 68781 | UT | 68781UT0140005 | 68781UT0140005-03 | Emergency Transportation/Ambulance | No Charge | | No Charge | 50% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | | Covered | No | | | | | | | Yes | No | No | No | 76 |
| 2014 | TX | 87226 | HIOS | 5 | 01/21/2014 08:29:49 AM | 87226 | TX | 87226TX0030008 | 87226TX0030008-02 | Transplant | $0 | | $0 | 0% | | 100% | | | Covered | | | | | | | Additional EHB Benefit | Yes | Yes | No | No | 117 |
| 2014 | LA | 97176 | HIOS | 9 | 01/21/2014 08:29:49 AM | 97176 | LA | 97176LA0370001 | 97176LA0370001-01 | Urgent Care Centers or Facilities | No Charge | | No Charge | 20% Coinsurance after deductible | | 40% Coinsurance after deductible | Yes | | Covered | No | | | | | | | Yes | No | No | No | 73 |
| 2014 | ID | 60597 | SERFF | 9 | 10/16/2013 07:58:29 PM | 60597 | ID | 60597ID0160005 | 60597ID0160005-01 | Chiropractic Care | No Charge after deductible | | No Charge after deductible | No Charge after deductible | | 50% Coinsurance after deductible | Yes | | Covered | | 15 | Visit(s) per Year | | | Services of a chiropractor or acupuncturist for medically necessary diagnosis and treatment of illness or injury. Benefits are subject to a maximum combined benefit of fifteen visits per person per calendar year. That includes coverage for chiropractic manipulation. Benefits do not include payment for pregnancy or childbirth services or drugs, homeopathic medicines, chiropractic massage therapy, or homeopathic supplies provided or ordered by a chiropractor or alternative care provider. | Substantially Equal | Yes | Yes | No | No | 94 |
| 2014 | FL | 56503 | HIOS | 6 | 03/19/2014 07:06:49 AM | 56503 | FL | 56503FL1480004 | 56503FL1480004-02 | X-rays and Diagnostic Imaging | $0 | | $0 | 0% | | 0% | Yes | | Covered | | | | | | | | No | No | No | No | 109 |
| 2014 | FL | 48121 | HIOS | 12 | 10/15/2013 07:27:56 AM | 48121 | FL | 48121FL0020009 | 48121FL0020009-02 | Congenital Anomaly, including Cleft Lip/Palate | $0 | | $0 | 0% | | 0% | | Yes | Covered | | | | | | | Additional EHB Benefit | Yes | Yes | No | No | 132 |
| 2014 | FL | 16842 | HIOS | 6 | 01/17/2014 09:36:20 AM | 16842 | FL | 16842FL0120041 | 16842FL0120041-03 | Delivery and All Inpatient Services for Maternity Care | No Charge | | No Charge | 10% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | Yes | Covered | No | | | | | | | Yes | Yes | No | No | 83 |
| 2014 | FL | 16842 | HIOS | 6 | 01/17/2014 09:36:20 AM | 16842 | FL | 16842FL0120070 | 16842FL0120070-02 | Specialist Visit | $0 | | $0 | 0% | | 0% | Yes | | Covered | No | | | | | | | No | No | No | No | 62 |
| 2014 | AZ | 88925 | HIOS | 5 | 01/17/2014 09:36:20 AM | 88925 | AZ | 88925AZ0010021 | 88925AZ0010021-03 | Orthodontia - Adult | | | | | | | Yes | | Not Covered | | | | | | | Other Law/Regulation | | | | | 114 |
| 2014 | IA | 27651 | SERFF | 5 | 11/27/2013 09:24:34 AM | 27651 | IA | 27651IA0050010 | 27651IA0050010-01 | Mental/Behavioral Health Outpatient Services | $50 | | $0 | No Charge | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | Quantitative limit units apply, see EHB benchmark. | | No | No | No | No | 84 |
| 2014 | LA | 67202 | HIOS | 9 | 01/15/2014 07:08:32 AM | 67202 | LA | 67202LA0040007 | 67202LA0040007-01 | Specialty Drugs | No Charge | | No Charge | 25% | | 25% | Yes | | Covered | | | | | | | | No | No | No | No | 91 |
| 2014 | WI | 47342 | HIOS | 11 | 07/25/2014 04:54:18 PM | 47342 | WI | 47342WI0050009 | 47342WI0050009-00 | Specialist Visit | $60 | | $0 | No Charge | | 100% | Yes | | Covered | | | | | | | | No | No | No | No | 62 |
| 2014 | IL | 36096 | SERFF | 10 | 01/22/2014 11:51:12 AM | 36096 | IL | 36096IL0810002 | 36096IL0810002-02 | Routine Eye Exam for Children | $0 | | $0 | 0% | | 0% | Yes | | Covered | Yes | 1 | Visit(s) per Year | | | | Substantially Equal | No | Yes | No | No | 102 |
