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 re 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 $250 Copayment per day up to $1,250 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 $200 Copayment Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 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 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 $250 Copayment per day up to $1,250 per admission Hospital - Outpatient: After Deductible, Enrollee pays $200 Copayment Outpatient Services: After Deductible, Enrollee pays $30 primary care provider services Copayment or $50 specialty care provider services Copayment Exclusions: Confinement, treatment or service that results from an illness or injury arising out of or in the course of any employment for wage or profit including injuries, illnesses or conditions incurred as a result of self-employment; PEBB_VA_2024 33