The Medical Savings Account Experts

Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association.

Regence BlueCross BlueShield - Online Application

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Benefit Schedule
Evolve HSA 50 | Evolve HSA 80 | Evolve HSA 100 | Optional Dental Coverage
Rate Schedule
Evolve HSA 50 | Evolve HSA 80 | Evolve HSA 100

Medical Plan Limitations and Exclusions

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 and terminates nine months following the effective date of coverage.

Medical limitations and exclusions
Regence Evolve Core
Regence Evolve Plus
Regence Evolve HSA Plans
Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery
Excluded
$2,500 per lifetime maximum benefit
Excluded
Chemical Dependency Treatment
Excluded
Excluded
Excluded
Cosmetic/Reconstructive Services and Supplies
Excluded
Excluded
Excluded
Counseling in the Absence of Illness
Excluded
Excluded
Excluded
Custodial Care
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
Military Service Related Conditions
Excluded
Excluded
Excluded
Motor Vehicle Coverage and Other Insurance Liability
Excluded
Excluded
Excluded
Neurodevelopmental Therapy Services
Excluded
Excluded
Excluded
Non-Direct Patient Care
Excluded
Excluded
Excluded
Nutritional Counseling (except as provided for diabetic education)
Excluded
Excluded
Excluded
Obesity or Weight Reduction/Control
Excluded
Excluded
Excluded
Orthognathic Surgery (except for congenital conditions, injury, and sleep apnea)
Excluded
Excluded
Excluded
Orthotics (except diabetic orthotics)
Excluded
$500 per-calendar-year maximum benefit
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
Excluded
Excluded
Excluded
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

 

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