Oregon Medical Insurance > PacificSource Health Plans > Elect Plan Exclusions

Benefit Limitations & Exclusions

Your policy contains dollar limitations on specific benefits.

Cosmetic/reconstructive services and supplies:
Services, supplies, and drugs, primarily for cosmetic or reconstructive purposes and any complications as a result of non-covered cosmetic or reconstructive surgery are excluded. Cosmetic or reconstructive services and supplies are performed primarily to improve appearance and not to restore impaired function of the body, regardless of whether the area to be treated is normal or abnormal.

Elective surgery or procedures
for a condition that does not require immediate attention and for which a delay would not have a substantial likelihood of adversely affecting the health of the patient, including, but are not limited to, sterilization when not performed in conjunction with a newborn delivery, are excluded for six months following effective date.

Family planning:
Services and supplies for family planning (except sterilization), artificial insemination, in vitro fertilization, diagnosis/treatment of infertility, frigidity, erectile dysfunction, or surgery to reverse voluntary sterilization are excluded.

Hearing aids:
Fitting, provision, or replacement of hearing aids are excluded.

Immunizations:
Immunizations recommended for, or in anticipation of, exposure through travel or work are not covered in any event.

Infertility:
Services and supplies, diagnostic lab and x-ray studies, surgery, treatment, or prescriptions to diagnose, prevent, or cure infertility or to induce fertility (including Gamete and/or Zygote Interfallopian Transfer; i.e. GIFT or ZIFT) are excluded. However, medically necessary medication to preserve fertility during treatment with cytotoxic chemotherapy is covered. For purposes of this policy, infertility is defined as:

• Male: Low sperm counts or the inability to fertilize an egg.
• Female: The inability to conceive or carry a pregnancy to 12 weeks.

Massage, massage therapy, or neuromuscular re-education
are excluded.

Mental health:
Outpatient mental health treatment is not covered. Except for the initial diagnostic exam, PacificSource will not pay for services and supplies from a mental health or other healthcare provider for the following diagnoses and/or diagnostic categories: mental retardation, learning disorders, motor skills disorders, communication disorders, pervasive developmental disorders, disruptive behavior disorders, factitious disorders, sexual and gender identity disorders, impulse control disorders, paraphilias except for pedophilia, relational problems, caffeine or nicotine-related disorders, and the category of “additional conditions that may be a focus of clinical attention.” This exclusion applies to developmental delays and disorders, learning disorders, sensory integration disorders, and conduct disorders.

The following treatment types are excluded: neurodevelopmental therapy, sensory integration training, biofeedback (except as specifically provided for under Covered Services), hypnotherapy, academic skills training, narcosynthesis, and social skills training. Recreation therapy is covered only as a part of
mental health inpatient or residential admission.

The following are also excluded: courtmandated diversion and chemical dependency education classes; courtmandated psychological evaluations for child custody determinations; mental examinations for the purpose of legal rights adjudication; psychological testing and evaluations not provided as an adjunct to treatment or diagnosis of a mental disorder; voluntary support groups such as Alcoholics Anonymous; adolescent wilderness treatment programs; treatments or services for career counseling, personal growth, relaxation, stress management, parenting skills, or family education; assertiveness training; image therapy; marathon group therapy; sensory movement group therapy; sensitivity training; and psychological evaluation for sexual dysfunction or inadequacy.

Otitis media surgery (inner or middle ear infection)
is excluded for six months following effective date.

Screening tests:
Services and supplies, including imaging and screening exams performed for the sole purpose of screening (including but not limited to total body CT imaging, CT colonography, and bone density testing) are excluded, except to the extent covered under the policy’s preventive care benefits.

Sexual disorders:
Services or supplies for the treatment of sexual dysfunction or inadequacy, as well as those related to sex change procedures, are excluded.

Sleep apnea, sleeping disorders, and sleep studies:
Services or supplies for the treatment of sleep apnea or other sleeping disorders, including expense for sleep studies, are excluded.

Snoring:
Services or supplies for the diagnosis or treatment of snoring and/or upper airway resistance disorders, including somnoplasty, are excluded.

Speech therapy:
Therapy for developmental language disorders, phonological disorders, and learning disorders, as well as oral/facial motor therapy for strengthening and coordination of speech-producing musculature and structures, are excluded.

Temporomandibular joint (TMJ):
Advice or treatment, including physical therapy and/or oromyofascial therapy, either directly or indirectly for temporomandibular joint dysfunction, myofascial pain, or any related appliances is excluded from coverage.

Tonsils or adenoids removal,
with or without myringotomy, is excluded for six months following effective date.

Please note: This is not a complete listing. This listing of exclusions is not intended to be part of the policy, and only the language of the actual policy is final and binding. Please see the Exclusions and Covered Services sections in your policy for complete information.