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Oregon Medical Insurance > Regence BlueCross BlueShield of Oregon > Plan Exclusions

Providence Health Plans

Limitations and Exclusions

 
BlueSelections
Regence HSA
Basic
Plus
Premier
Acupuncture
Excluded
Excluded
Alcoholism
Limited to $4,500 in any 24 month period
Limited to $4,500 in any 24 month period
Ambulance
Not limited
$5,000 annual limit
Cosmetic/Reconstructive Surgery
Excluded
Excluded
Custodial Care and Rest Cures
Excluded
Excluded
Drug abuse / Addiction treatment
Excluded
Excluded
Durable Medical Equipment
Not limited
$2,500 annual limit
Family Planning
(except sterilization)
Excluded
Excluded
Growth Hormone Benefit
Excluded
$20,000 annual limit
Hearing Aids
Excluded
Excluded
Home Health Care
130 visits per calendar year
130 visits per calendar year
Mental Health Treatment
Inpatient covered only, 30 day maximum
Excluded
Obesity or Weight Control
Excluded
Excluded
Orthognatic Surgery
Excluded
Excluded
Outpatient Counseling
Excluded
Excluded
Rehabilitative Care (inpatient)
30 days per calendar year
$15,000 annual limit
Rehabilitative Care (outpatient)
30 sessions per calendar year
$1,500 annual limit
Skilled Nursing Facility Care
14 days per calendar year
14 days per stay
Spinal Manipulation
Excluded
Excluded
TMJ
$1,000 per calendar year
$1,000 per calendar year
Tobacco Addiction Treatment
Excluded
Excluded
Organ Transplant
24-month waiting period $250,000 lifetime max
24-month waiting period $250,000 lifetime max
6 month waiting period for pre-existing conditions
This chart does not contain all limitations and exclusions. Please refer to your contract for a complete list and more in-depth explanation of benefits and the limitations and exclusions that apply.

 
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