Regence BlueShield
| Regence RealValue | Regence Evolve Core | Regence Evolve Plus | Regence Evolve HSA Plans | |
|---|---|---|---|---|
| Acupuncture | Excluded | 6 visits per calendar year | 6 visits per calendar year | 6 visits per calendar year |
| Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery | Excluded | Excluded | Deductible and 50% coinsurance | Excluded |
| Chemical Dependency Treatment | Excluded | Excluded | Excluded | Excluded |
| Cosmetic/Reconstructive Services and Supplies | Excluded | Excluded | Excluded | Excluded |
| Counseling in the Absence of Illness | Excluded | Excluded | Excluded | Excluded |
| Custodial Care | Excluded | Excluded | Excluded | Excluded |
| Detoxification | Excluded | Deductible and CAT 1 coinsurance | Deductible and CAT 1 coinsurance | Deductible and CAT 1 coinsurance |
| Dialysis | Excluded | Deductible and coinsurance | Deductible and coinsurance | Deductible and coinsurance |
| Durable Medical Equipment, exceptions apply | Excluded | Deductible and coinsurance | Deductible and coinsurance | Deductible and coinsurance |
| Family Planning | Excluded | Deductible and coinsurance | Deductible and coinsurance | Deductible and coinsurance |
| Hospice | 14 days inpatient/outpatient per lifetime | 14 days inpatient/outpatient per lifetime | 14 days inpatient/outpatient per lifetime | 14 days inpatient/outpatient per lifetime |
| Hospitalization for Dentistry | Excluded | Excluded | Excluded | Excluded |
| Home Health Care | Excluded | 130 visits per calendar year | 130 visits per calendar year | 130 visits per calendar year |
| Infertility Treatment | Excluded | Excluded | Excluded | Excluded |
| Maternity (routine and complications) | Excluded | Excluded | Deductible and coinsurance | Excluded |
| Medications without a Prescription Order | Excluded | Excluded | Excluded | Excluded |
| Neurodevelopmental Therapy Services | Excluded | Excluded | Excluded | Excluded |
| Motor Vehicle Coverage and Other Insurance Liability | Excluded | Excluded | Excluded | Excluded |
| Neurodevelopmental Therapy Services | Excluded | Excluded | Excluded | Excluded |
| Obesity or Weight Reduction/Control | Excluded | Excluded | Excluded | Excluded |
| Orthognathic Surgery (except for congenital conditions, injury, and sleep apnea) | Excluded | Excluded | Excluded | Excluded |
| Orthotics (except diabetic orthotics) | Excluded | Excluded | Deductible and Coinsurance | Excluded |
| Private Duty Nursing | Excluded | Excluded | Excluded | Excluded |
| Prostheses | Excluded | Deductible and Coinsurance | Deductible and Coinsurance | Deductible and Coinsurance |
| Rehabilitative Service | Inpatient: 10 days per
calendar year Outpatient: 15 visits per calendar year |
Inpatient: 10 days per calendar year Outpatient: 25 visits per calendar year |
Inpatient: 10 days per calendar year Outpatient: 25 visits per calendar year |
Inpatient: 10 days per calendar year Outpatient: 25 visits per calendar year |
| Routine Foot Care | Excluded | Excluded | Excluded | Excluded |
| Routine Hearing Exam | Excluded | Excluded | Excluded | Excluded |
| Routine Vision Exam and Hardware | Excluded | Excluded | Combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum | Excluded |
| Self-Help, Self-Care, Training or Instructional Programs | Excluded | Excluded | Excluded | Excluded |
| Services to Alter Refractive Character of the Eye | Excluded | Excluded | Excluded | Excluded |
| Sexual Reassignment Treatment and Surgery | Excluded | Excluded | Excluded | Excluded |
| Sexual Dysfunction | Excluded | Excluded | Excluded | Excluded |
| Skilled Nursing Facility Care | 30 inpatient days per calendar year | 30 inpatient days per calendar year | 30 inpatient days per calendar year | 30 inpatient days per calendar year |
| Spinal Manipulations | Excluded | 10 spinal manipulations per calendar year | 10 spinal manipulations per calendar year | 10 spinal manipulations per calendar year |
| Temporomandibular Joint Disorder | Excluded | Excluded | Excluded | Excluded |
| Temporomandibular Joint (TMJ) Disorder Treatment | Excluded | Excluded | Excluded | Excluded |
| Fees, Taxes, Interest | Excluded | Excluded | Excluded | Excluded |
| Government Programs | Excluded | Excluded | Excluded | Excluded |
| Investigational Services | Excluded | Excluded | Excluded | Excluded |
| Military Service Related Conditions | Excluded | Excluded | Excluded | Excluded |
| Motor Vehicle Coverage and Other Insurance Liability | Excluded | Excluded | Excluded | Excluded |
| Non-Direct Patient Care | Excluded | Excluded | Excluded | Excluded |
| Personal Comfort Items | Excluded | Excluded | Excluded | Excluded |
| Physical Exercise Programs and Equipment | Excluded | Excluded | Excluded | Excluded |
| Riot, Rebellion and Illegal Acts | Excluded | Excluded | Excluded | Excluded |
| Services and Supplies Provided by a Member of Your Family | Excluded | Excluded | Excluded | Excluded |
| Services and Supplies That Are Not Medically Necessary | Excluded | Excluded | Excluded | Excluded |
| Third-Party Liability | Excluded | Excluded | Excluded | Excluded |
| Travel and Transportation Expenses (other than covered ambulance services) | Excluded | Excluded | Excluded | Excluded |
| Work-Related Conditions | Excluded | 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 | ||||
Other Considerations
Waiting Periods There is a nine-month waiting period that must be met before benefits are available for pre-existing conditions. (The pre-existing conditions waiting period does not apply to members up to age 19.) By pre-existing condition, we mean a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received or for which a prudent layperson would have sought medical advice, diagnosis, care or treatment, within the six-month period before the effective date of coverage. The exclusion period will end nine months following your effective date of coverage.
This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. Please refer to the policy for a complete list of benefits, limitations and exclusions.
