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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?
Because of the high-risk nature of bariatric surgery, the plans cover just two surgeries and only in very specific circumstances when approved by a plan medical director:
- For members ages 21-64, the plans cover either the Roux-en-Y surgery or laparoscopic adjustable gastric banding surgery. Which surgery a member has is a decision made by the member and the surgeon at the Center of Excellence where the surgery will take place AFTER the member meets all criteria for coverage.
- For members ages 18-20, the plans cover only the laparoscopic adjustable gastric banding surgery.
Members ages 65 or older should check with Medicare for coverage. If Medicare approves bariatric surgery, the plans will pay second after Medicare.
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 dramatic and permanent lifestyle changes, these surgeries are not for everyone. Members must first meet strict criteria to be considered. The list of requirements includes but is not limited to having a body mass index of 40 or higher and having a chronic disease such as diabetes, high cholesterol, or high blood pressure. See "Criteria for Coverage" for complete information.
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 lose weight 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.
The final decision to approve surgery is made by a plan medical director after you meet all presurgical requirements. Once approved, you must use providers and facilities designated as Centers of Excellence by UMP.
Who will not be considered for coverage of bariatric surgery?
Members who have had any bariatric surgery within the last 10 years or any prior bariatric surgery covered by a PEBB health plan are not eligible for coverage.
*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. If you do not complete the presurgical program or proceed to surgery, fees paid for a weight-loss program are not refundable.