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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 Accomplish Bariatric Nutrition Services*, which specializes in helping bariatric surgery patients achieve safe weight loss before and after surgery. An Accomplish nutritionist will help you lose 5 percent of your verified program entrance weight after you meet the initial criteria for coverage. This weight loss is required before you can be approved for bariatric surgery.
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 Accomplish enrollment fee is $1,450. The plan does not cover this service and members are responsible for the full program cost. The $1,450 cost 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 the Accomplish program may not be refundable. Following surgery, all fees paid to Accomplish are nonrefundable.