provider services Copayment or $30 specialty care Services related to a healthy diet to prevent obesity are provider services Copayment covered as Preventive Services. See Preventive Services for additional information. Exclusions: Nutritional supplements; weight control self-help programs or memberships, such as Weight Watchers, Jenny Craig, or other such programs Nutritional Therapy Medical formula necessary for the treatment of After Deductible, Enrollee pays nothing phenylketonuria (PKU), specified inborn errors of metabolism, or other metabolic disorders. Enteral therapy is covered when Medical Necessity criteria After Deductible, Enrollee pays 20% coinsurance are met and when given through a PEG, J tube, or orally or for an eosinophilic gastrointestinal disorder. Necessary equipment and supplies for the administration of enteral therapy are covered as Devices, Equipment and Supplies. Parenteral therapy (total parenteral nutrition) After Deductible, Enrollee pays nothing Necessary equipment and supplies for the administration of parenteral therapy are covered as Devices, Equipment and Supplies. Exclusions: Any other dietary formulas or medical foods; oral nutritional supplements that do not meet Medical Necessity criteria or are not related to the treatment of inborn errors of metabolism; special diets; prepared foods/meals Obesity Related Surgical Services Bariatric surgery is covered when KFHPWA criteria are met. Hospital - Inpatient: After Deductible, Enrollee pays $150 Copayment per day up to $750 per Bariatric surgery related services require Preauthorization. admission Services related to obesity screening and counseling are Hospital - Outpatient: After Deductible, Enrollee covered as Preventive Services. pays $150 Copayment Outpatient Services: After Deductible, Enrollee pays $15 primary care provider services Copayment or $30 specialty care provider services Copayment Exclusions: Obesity treatment and treatment for morbid obesity for any reason including any medical services, drugs, supplies, regardless of co-morbidities, except as described above; specialty treatment programs such as weight control self-help programs or memberships, such as Weight Watchers, Jenny Craig or other such programs; medications and related physician visits for medication monitoring PEBB_CA_2024 32