Regence BlueCross BlueShield of Oregon

A pre-existing condition is a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period before the effective date of coverage. The pre-existing condition period terminates six-months following the effective date of coverage.

Medical Plan Limitations and Exclusions
  Regence Evolve Core Regence Evolve Plus Regence Evolve HSA Plans
Alcoholism Treatment $4,500 every two calendar years maximum (inpatient and outpatient combined) $4,500 every two calendar years maximum (inpatient and outpatient combined) $4,500 every two calendar years maximum (inpatient and outpatient combined)
Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery Excluded $2,500 per lifetime maximum benefit Excluded
Complementary Care (Acupuncture, chiropractic care and the services of an acupuncturist, a chiropractor and a naturopath) Excluded Limited to $500 per calendar year maximum benefit; not subject to deductible or coinsurance maximum. Does not include tobacco cessation services. Excluded
Cosmetic/Reconstructive Services and Supplies Excluded Excluded Excluded
Counseling in the Absence of Illness Excluded Excluded Excluded
Custodial Care Excluded Excluded Excluded
Drug Abuse Treatment Excluded Excluded Excluded
Fees, Taxes, Interest Excluded Excluded Excluded
Government Programs Excluded Excluded Excluded
Hospitalization for Dentistry Excluded Excluded Excluded
Infertility Treatment Excluded Excluded Excluded
Investigational Services Excluded Excluded Excluded
Medications without a Prescription Order Excluded Excluded Excluded
Mental Health Treatment Excluded Inpatient: 6 days per
calendar year
Outpatient: 12 visits
per calendar year		 Inpatient: 6 days per
calendar year
Outpatient: 12 visits
per calendar year
Military Service Related Conditions Excluded Excluded Excluded
Motor Vehicle Coverage and Other Insurance Liability Excluded Excluded Excluded
Non-Direct Patient Care Excluded Excluded Excluded
Non-Duplication of Medicare Excluded Excluded Excluded
Obesity or Weight Reduction/Control Excluded Excluded Excluded
Orthognathic Surgery (except for congenital conditions, injury, and sleep apnea) Excluded Excluded Excluded
Personal Comfort Items Excluded Excluded Excluded
Physical Exercise Programs and Equipment Excluded Excluded Excluded
Private Duty Nursing Excluded Excluded Excluded
Riot, Rebellion and Illegal Acts Excluded Excluded Excluded
Routine Foot Care Excluded Excluded Excluded
Routine Hearing Exams Excluded Excluded Excluded
Self-Help, Self-Care, Training or Instructional Programs Excluded Excluded Excluded
Services and Supplies Provided by a Member of Your Family Excluded Excluded Excluded
Services and Supplies That Are Not Medically Necessary Excluded Excluded Excluded
Services to Alter Refractive Character of the Eye Excluded Excluded Excluded
Sexual Reassignment Treatment and Surgery Excluded Excluded Excluded
Sexual Dysfunction Excluded Excluded Excluded
Temporomandibular Joint (TMJ) Disorder Treatment Excluded Excluded Excluded
Third-Party Liability Excluded Excluded Excluded
Tobacco Addiction Treatment $500 per lifetime maximum benefit $500 per lifetime maximum benefit $500 per lifetime maximum benefit
Travel and Transportation Expenses (other than covered ambulance services) Excluded Excluded Excluded
Routine Vision Exam and Hardware Excluded Combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum Excluded
Work-Related Conditions Excluded Excluded Excluded
This chart does not contain all limitations and exclusions. Please refer to your policy for a complete list of benefits and the limitations and exclusions that apply