Common use of Bariatric Surgery Benefits Clause in Contracts

Bariatric Surgery Benefits. Benefits are available for bariatric surgery services. These Benefits include facility and Physician services for the surgical treatment of morbid obesity. Services for residents of designated California counties Blue Shield has a network of Participating Providers for bariatric surgery services in certain designated counties within California. If you live in a designated county, services are only covered if you receive them from one of these Participating Providers. Bariatric surgery services designated counties Imperial Orange San Xxxxx Xxxx Riverside Santa Xxxxxxx Los Angeles San Xxxxxxxxxx Xxxxxxx Travel expense reimbursement for residents of designated counties You may be eligible for reimbursement of your travel expenses for bariatric surgery services if you meet the following conditions: • Live in a designated county; • Live at least 50 miles away from the nearest bariatric surgery services provider in the network; • Receive prior authorization for travel expense reimbursement; and • Submit receipts and any other documentation of your expenses to Blue Shield. Reimbursable bariatric surgery travel expenses Expense type Maximum reimbursement Limitations & exclusions Transportation to and from the facility $130/roundtrip • Maximum of 3 roundtrips (pre-surgery, surgery, follow- up) • 1 companion is covered for a maximum of 2 roundtrips (surgery & surgery follow-up) Hotel accommodations $100/day • Maximum of 2 trips, 2 days/trip (pre-surgery & post-surgery follow-up) for you and 1 companion • 1 companion alone may be reimbursed for a maximum of 4 days during your surgery admission • Hotel stays are limited to 1 double-occupancy room. Only the room is covered. All other hotel expenses are excluded Related reasonable expenses $25/day/Member • Maximum of 4 days/trip • Expenses for tobacco, alcohol, drugs, phone, television, delivery, and recreation are excluded Services for residents of non-designated counties

Bariatric Surgery Benefits. Benefits are available for bariatric surgery services. These Benefits include facility and Physician services for the surgical treatment of morbid obesity. Services for residents of designated California counties Blue Shield has a network of Participating Providers for bariatric surgery services in certain designated counties within California. If you live in a designated county, services are only covered if you receive them from one of these Participating Providers. Bariatric surgery services designated counties Imperial Orange San Xxxxx Xxxx Riverside Santa Xxxxxxx Los Angeles San Xxxxxxxxxx Xxxxxxx Travel expense reimbursement for residents of designated counties You may be eligible for reimbursement of your travel expenses for bariatric surgery services if you meet the following conditions: •  Live in a designated county; •  Live at least 50 miles away from the nearest bariatric surgery services provider in the network; •  Receive prior authorization for travel expense reimbursement; and •  Submit receipts and any other documentation of your expenses to Blue Shield. Reimbursable bariatric surgery travel expenses Expense type Maximum reimbursement Limitations & exclusions Transportation to and from the facility $130/roundtrip •  Maximum of 3 roundtrips (pre-surgery, surgery, follow- up) •  1 companion is covered for a maximum of 2 roundtrips (surgery & surgery follow-up) Hotel accommodations $100/day •  Maximum of 2 trips, 2 days/trip (pre-surgery & post-surgery follow-up) for you and 1 companion •  1 companion alone may be reimbursed for a maximum of 4 days during your surgery admission •  Hotel stays are limited to 1 double-occupancy room. Only the room is covered. All other hotel expenses are excluded Related reasonable expenses $25/day/Member •  Maximum of 4 days/trip •  Expenses for tobacco, alcohol, drugs, phone, television, delivery, and recreation are excluded Services for residents of non-designated counties If you do not reside in a designated county, bariatric surgery services are covered like other surgery services from Participating or Non-Participating Providers. See the Hospital services and Physician and other professional services sections for more information. Blue Shield does not reimburse travel expenses associated with bariatric surgery services for residents of non-designated counties.