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 15% Plan Coinsurance 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 $500 Copayment per admission Bariatric surgery related services require Preauthorization. Hospital - Outpatient: After Deductible, Enrollee Services related to obesity screening and counseling are pays 15% Plan Coinsurance covered as Preventive Services. Outpatient Services: Enrollee pays $20 Copayment for primary care provider office visits After Deductible, Enrollee pays 15% Plan Coinsurance for specialty care provider office visits 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 On the Job Injuries or Illnesses On the job injuries or illnesses. Office of Worker’s Compensation Programs (OWCP) or similar Federal or State agency pays through a third-party settlement: Not covered; Enrollee pays 100% of all charges After the third-party settlement maximum is paid: Hospital - Inpatient: After Deductible, Enrollee pays $500 Copayment per admission Hospital - Outpatient: After Deductible, Enrollee pays 15% Plan Coinsurance Outpatient Services: Enrollee pays $20 Copayment PEBB_SCA_2024 33