Providence Health Plans of Oregon

Medical & Rx Limitations and Exclusions

Exclusion period
An “exclusion period” is the period of time during which specified treatments and services are excluded from coverage. Exclusion periods are waived for a newborn or adopted child if the child is enrolled on the plan within 60 days of birth or adoption placement.

Six month pre-existing condition exclusion period
A “pre-existing condition” is a medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the effective date of coverage. If you have a pre-existing condition, then you will need to be covered six continuous months on one of our plans before that condition will be covered.

Other Exclusion Periods
You will need to be covered for 12 continuous months on one of our plans before treatment and services for elective procedures will be covered. An elective procedure is one that can be reasonably postponed for treatment during the limitation period). You will need to be covered for 24 continuous months on one of our plans before we pay benefits for organ transplants.

Creditable Coverage
If you were covered on another group or individual health plan within 63 days before your effective date of coverage with Providence, then you probably have what is called “creditable coverage.” Your creditable coverage will be applied month for month toward decreasing the number of months in the plan exclusion periods. For example, if you have 12 months of creditable coverage, the 6-month pre-existing condition exclusion period and the 12-month exclusion periods would be waived. You would only have to be covered on the plan an additional 12 months to meet the 24-month organ transplant exclusion period.

You will need to give us a copy of your Certificate of Coverage so we can apply your creditable coverage months toward the exclusion periods. You can obtain your Certificate of Creditable Coverage by contacting your prior health carrier.

Limitations
Certain covered services have a plan coverage maximum for a set period of time, usually a calendar year. Limits are either set by a maximum dollar amount or a maximum day or visit amount. Once the plan maximum is met, you will be responsible for the remaining costs until the new limitation period begins. The chart below lists the services with limitations, and the maximum coverage amounts and limitation periods that apply to each service.

Medical Exclusions

• Alternative care, including acupuncture and naturopathic care.
• Services and supplies for chemical dependency, except as noted for alcohol treatment.
• Cosmetic surgery.
• Custodial care and private nursing services.
• Dental care, including orthognathic surgery.
• Experimental/investigational procedures.
• Eye surgery which alters the refractive character of the eye, including laser eye and radial keratotomy.
• Services and supplies for family planning.
• Services and supplies for fertility/infertility treatment, including in vitro fertilization.
• Routine foot care, except for diabetes.
• Genetic testing.
• Hearing aids/devices, screening and exams.
• Home births and all related services.
• Massage therapy.
• Certain mental health services, including all residential/day treatment, treatment of developmental or learning disabilities; and selfhelp programs, including family, marriage, sex and career counseling in the absence of illness.
• Physical exams primarily for camps, sports, insurance, licensing, employment, or other third-party purposes.
• Services, supplies and prescription drugs for sexual dysfunction or sexual transformation.
• Voluntary sterilization or termination of pregnancy.
• Temporomandibular joint (TMJ) services.
• Treatment for tobacco addiction.
• Routine vision exams and eyeglasses.
• Weight loss programs and other services and supplies for the treatment of obesity, including surgery.
• Services for injury/illness sustained as a result of any work for wage or profit.
• Services covered by motor vehicle insurance or other liability insurance.

Prescription Drug Exclusions

• Drugs that are not provided in accordance with the plan formulary management program.
• Drugs used for weight loss or cosmetic purposes.
• Drugs prescribed that do not relate directly to the treatment of a covered illness or injury.
• Over-the-counter (OTC) drugs, medications, or vitamins and prescription drugs for which there are OTC therapeutic equivalents.
• Drugs used in the treatment of fungal nail conditions.
• Drugs used in the treatment of the common cold.
• Experimental or investigational drugs.
• Intrauterine devices (IUDs), diaphragms, topical, implantable and oral contraceptives regardless of intended use.
• Amphetamines and amphetamine derivatives, except when used in the treatment of narcolepsy or hyperactivity in children and adults.
• Drugs used to treat all sexual dysfunctions in either men or women, regardless of cause. Drugs required for sexual transformation.
• Smoking cessation drug therapy, including nicotine replacement therapy.
• Drugs used to treat shift-sleep disorder, drug induced fatigue or general fatigue.
• Drugs used for the treatment of fertility/infertility.
• Fluoride, for members over the age of 10 years old.
• Drugs to stimulate hair growth (i.e., topical minoxidil) or other similar drug preparations.
• Injectable medications unless they are: intended for self-administration; labeled by FDA for self administration; and on the Plan list of “Self Administered Injectable Drugs.”
• Drugs used in the treatment of shift work sleep disorder, drug induced fatigue, general fatigue and idiopathic hypersomnia.
• Drugs that are placed on prescription-only status by federal or state mandate outside of required FDA-status assignment.

The Oregon Department of Consumer Business Services requires that we provide the following information:

• Read the policy carefully. This Summary of Benefits provides a very brief description of the important features of these policies. Please note that this outline is not intended to be a part of the insurance contract. Only the language of the contract issued by the insurer is final and binding.
• Before you add new coverage to your current coverage, you should review both contracts to ensure that you are not purchasing unnecessary benefits.
• If you have any questions that are not answered by this disclosure statement, be sure to ask us. Call 888.708.0812.
• If you are offered a contract and purchase it, read it carefully as soon as you receive it. Because it is an individual contract, you will have an opportunity to send it back within 10 days and obtain a premium refund.
• If you decline coverage under a group health benefit plan in order to retain or obtain coverage under an individual health benefit plan, you will be considered a late enrollee if you seek subsequent enrollment in a group.
• Be sure to fill out all portions of your application completely and truthfully. If misstatements are made or information about your health is omitted from the application the contract may be voided or claims unpaid..