Oregon Medical Insurance > LifeWise Health Plan of Oregon > Plan Exclusions

General Exclusions & Limitations

Benefit plans typically have exclusions and limitations—what the plans do not cover. The following are general exclusions and limitations for the LifeWise benefit plans:

What is not covered

Benefits are not provided for services, treatment, surgery, drugs or supplies for any of the following:

• Alcohol dependency treatment services (unless optional alcohol endorsement is purchased)
• Biofeedback
• Chemical (drug addition) dependency
• Conditions arising from acts of war or service in the military
• Cosmetic or reconstructive services, except as specifically provided in the contract
• Dental services (except as allowed under the accident benefit included in the WiseChoices plan)
• Experimental or investigative services
• Hearing exams and aids
• Infertility
• Mental health
• Obesity/morbid obesity
• Orthognathic surgery (unless it meets medical criteria and as required by ORS 743.706)
• Over-the-counter or non-prescription drugs
• Services determined by us to be medically unnecessary
• Services in excess of specified benefit maximums
• Services payable by other types of insurance coverage
• Services received when you are not covered by this program
• Sexual dysfunction
• Sterilization reversal
• Treatment for work-related conditions for which benefits are provided by Workers’ Compensation or similar coverage
• Treatment of temporomandibular joint (TMJ) disorder

Waiting periods

There is a 6-month waiting period for pre-existing conditions.  A pre-existing condition is a medical condition that was diagnosed, or for which care, treatment, or advice was received or recommended in the 6 months prior to your effective date on your LifeWise plan.

Charges over the maximum allowable amount

You may be responsible for charges that exceed the maximum allowable amount for covered services from non-preferred providers.