| |
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 |
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