| 2014 | LA | 18802 | HIOS | 8 | 01/21/2014 08:29:49 AM | 18802 | LA | 18802LA0010006 | 18802LA0010006-00 | Orthodontia - Child | No Charge after deductible | | No Charge after deductible | 50% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | | | Yes | Yes | No | Yes | 111 |
| 2014 | AZ | 88925 | HIOS | 5 | 01/17/2014 09:36:20 AM | 88925 | AZ | 88925AZ0010042 | 88925AZ0010042-02 | Long-Term/Custodial Nursing Home Care | | | | | | | | | Not Covered | | | | | | | | | | | | 70 |
| 2014 | AZ | 53901 | HIOS | 7 | 01/16/2014 07:24:04 AM | 53901 | AZ | 53901AZ0730003 | 53901AZ0730003-00 | Allergy Testing | $60 | | No Charge | No Charge | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | | | No | No | No | No | 120 |
| 2014 | IN | 50816 | HIOS | 9 | 11/26/2013 01:14:08 PM | 50816 | IN | 50816IN0110068 | 50816IN0110068-00 | Orthodontia - Adult | | | | | | | | | Not Covered | | | | | | | | | | | | 114 |
| 2014 | OK | 87571 | HIOS | 9 | 01/21/2014 08:29:49 AM | 87571 | OK | 87571OK0320001 | 87571OK0320001-00 | Weight Loss Programs | | | | | | | | | Not Covered | | | | | | Not covered except under diabetes self-management. | | Yes | Yes | No | No | 101 |
| 2014 | WI | 91058 | HIOS | 3 | 09/02/2013 11:39:25 AM | 91058 | WI | 91058WI0060004 | 91058WI0060004-03 | Laboratory Outpatient and Professional Services | No Charge | | $0 | 0% | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | | | Yes | No | No | No | 108 |
| 2014 | TX | 87226 | HIOS | 5 | 01/21/2014 08:29:49 AM | 87226 | TX | 87226TX0030002 | 87226TX0030002-02 | Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $0 | | $0 | 0% | | 100% | Yes | | Covered | | | | | | | | Yes | Yes | No | No | 64 |
| 2014 | PA | 16481 | HIOS | 11 | 03/19/2014 07:06:49 AM | 16481 | PA | 16481PA0040001 | 16481PA0040001-01 | Inherited Metabolic Disorder - PKU | No Charge | | No Charge | No Charge | | 40% Coinsurance after deductible | | Yes | Covered | | | | | | | Additional EHB Benefit | No | No | No | No | 130 |
| 2014 | PA | 91303 | HIOS | 4 | 09/17/2013 04:07:07 PM | 91303 | PA | 91303PA0020002 | 91303PA0020002-01 | Cosmetic Surgery | | | | | | | | | | | | | | | | | | | | | 80 |
| 2014 | TX | 87226 | HIOS | 5 | 01/21/2014 08:29:49 AM | 87226 | TX | 87226TX0010005 | 87226TX0010005-01 | Rehabilitative Speech Therapy | No Charge | | $0 | 30% Coinsurance after deductible | | 100% | | | Covered | | | | | | | Additional EHB Benefit | Yes | Yes | No | No | 105 |
| 2014 | IN | 85320 | HIOS | 7 | 01/21/2014 08:29:49 AM | 85320 | IN | 85320IN0010020 | 85320IN0010020-01 | Basic Dental Care - Child | | | | | | | Yes | | Not Covered | | | | | | | Dental Only Plan Available | | | | | 110 |
| 2014 | IA | 71268 | SERFF | 8 | 01/23/2014 12:49:01 PM | 71268 | IA | 71268IA0080003 | 71268IA0080003-00 | Inpatient Physician and Surgical Services | No Charge | | No Charge | 30% Coinsurance after deductible | | 50% Coinsurance after deductible | Yes | | Covered | | | | | | | | Yes | No | No | No | 78 |
| 2014 | OK | 87571 | HIOS | 9 | 01/21/2014 08:29:49 AM | 87571 | OK | 87571OK0320002 | 87571OK0320002-00 | Non-Preferred Brand Drugs | $75 | | $75 | No Charge | | No Charge | Yes | | Covered | | | | | | When one month supply of prescription drugs are obtained from an out of network pharmacy - benefits will be provided at 50% of the eligible charge minus the applicable copay. | Substantially Equal | No | Yes | No | No | 90 |
| 2014 | SD | 60536 | SERFF | 4 | 09/16/2013 08:58:26 AM | 60536 | SD | 60536SD0010010 | 60536SD0010010-01 | Weight Loss Programs | | | | | | | | | Not Covered | | | | | | | | | | | | 101 |
| 2014 | AZ | 51485 | HIOS | 13 | 03/19/2014 07:06:49 AM | 51485 | AZ | 51485AZ0170006 | 51485AZ0170006-02 | Basic Dental Care - Adult | | | | | | | | | | | | | | | | | | | | | 113 |
| 2014 | GA | 93332 | HIOS | 8 | 01/16/2014 07:24:04 AM | 93332 | GA | 93332GA0710004 | 93332GA0710004-03 | Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | No Charge | | $0 | 20% Coinsurance after deductible | | 100% | Yes | | Covered | No | | | | | | | Yes | Yes | No | No | 64 |
| 2014 | NJ | 91661 | HIOS | 11 | 07/25/2014 04:54:18 PM | 91661 | NJ | 91661NJ2300004 | 91661NJ2300004-00 | Third Opinion | No Charge | | $0 | 30% Coinsurance after deductible | | 100% | | Yes | Covered | No | | | | | | Additional EHB Benefit | Yes | Yes | No | Yes | 141 |
| 2014 | WI | 47342 | HIOS | 11 | 07/25/2014 04:54:18 PM | 47342 | WI | 47342WI0050012 | 47342WI0050012-05 | Durable Medical Equipment | No Charge after deductible | | $0 | 0% Coinsurance after deductible | | 100% | Yes | | Covered | | | | | | | Above EHB | Yes | No | No | No | 95 |
| 2014 | MT | 30751 | OPM | 3 | 10/17/2013 08:32:07 AM | 30751 | MT | 30751MT0570004 | 30751MT0570004-04 | Skilled Nursing Facility | $0 Copay per Stay | | $0 Copay per Stay | 0% Coinsurance after deductible | | 20% Coinsurance after deductible | Yes | | Covered | Yes | 60 | Days per Benefit Period | | | | Substantially Equal | Yes | Yes | No | No | 81 |
| 2014 | OH | 64353 | SERFF | 5 | 10/15/2013 10:04:03 AM | 64353 | OH | 64353OH0010001 | 64353OH0010001-03 | Other Practitioner Office Visit (Nurse, Physician Assistant) | $50 | | $0 | No Charge | | 100% | Yes | | Covered | No | | | | | | | No | No | No | No | 63 |
