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For more information about qualifying for bariatric surgery, see "Related Items" below.
NOTE: "The plans" refers to UMP Classic and UMP CDHP.
Which surgeries are covered?
The plans cover only certain surgeries and only in very specific circumstances when approved by a plan medical director:
- For members ages 21 and older, the plans cover laparoscopic adjustable gastric banding, Roux-en-Y, or sleeve gastrectomy surgery as stated in "Bariatric Surgery Criteria for Coverage."
- For members ages 18-20, the plans cover only the laparoscopic adjustable gastric banding surgery as defined in Regence BlueShield medical policy and outlined in the Health Technology Assessment decision.
Retired members age 65 or older, for whom Medicare provides primary coverage, must check with Medicare for a determination about their M edicare coverage. Medicare covers some bariatric surgical procedures, like gastric bypass surgery and laparoscopic banding surgery, when you meet certain conditions related to morbid obesity. If Medicare approves bariatric surgery, the plans will pay second after Medicare, based on Medicare’s determination of coverage.
See here if you are age 64 and will be eligible for Medicare soon.
Who will be considered for coverage of bariatric surgery?
Because bariatric surgery requires significant, permanent lifestyle changes, members must first meet strict criteria to be considered. See "Criteria for Coverage" for complete information.
Bariatric (obesity) surgery is covered only in very specific clinical circumstances, including comorbid conditions, and must be preauthorized by the plan. The plan will cover the surgery only
if the patient meets all program requirements, including those for before and after surgery.
If you meet the initial criteria for coverage, you will be referred to a Regence case manager, who will refer you to a bariatric surgery center. You will be required to meet the plan's criteria for weight loss under a structured weight-loss program before being approved for bariatric surgery. Your assigned bariatric surgery center will determine how much weight you must lose and will work with your Regence case manager.
Once approved, you must use providers and facilities designated by UMP.
*The plan does not cover costs associated with weight-loss programs and members are responsible for the full program cost. This amount does not apply to your deductible or out-of-pocket maximum.