| |
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. |
Plan Updates 
