I:\Legal\LEGAL\ST PATRICK HOSPITAL-Medical\Plan Document ...

Medical BenefitsBody Mass Index (BMI) is calculated by dividing a person’s weight (in kilograms) by his/her height squared(in meters).Charges for Roux-En-Y Divided Gastric Bypass surgery or laparoscopic adjustable gastric banding (Lap-Band) surgery, and directly related presurgical assessment and or counseling, and directly related postsurgicalfollow-up care are covered up to the limits set out in the Schedule of Medical Benefits, subject tothe following conditions, which must be certified by the Montana Center for Treatment of Obesity at St.Patrick Hospital:1. A clinical history of unsuccessful diet and other weight management programs.2. The individual must undergo and successfully complete the pre-surgical evaluation at the MontanaCenter for Treatment of Obesity at St. Patrick Hospital, or a program at another bariatric program,that in the judgement of the Plan Administrator is substantially similar to the program required bythe Montana Center for Treatment of Obesity at St. Patrick Hospital. The program must includepost-operative follow-up.3. Must receive a positive assessment of surgery risk-benefit from all evaluating staff members of thepre-surgery program.4. Must be at least 18 years of age and less than 70 years of age.Charges incurred for weight reduction, weight loss, the treatment of obesity and the treatment of MorbidObesity/Clinically Severe Obesity are excluded for the following:1. Non surgical treatment of weight gain, weight reduction or weight maintenance including but notlimited to prescription drugs, vitamins, food supplements, counseling, diet and educationalprograms.2. Surgical procedures except for Roux-En-Y Divided Bypass Surgery or laparoscopic adjustablegastric banding) surgery.3. Any expenses incurred for which all of the conditions of the Bariatric Surgery Benefit of this Planhave not been met.4. Any redo or revision of a prior bariatric surgical procedure.5. A second bariatric surgical procedure, whether or not the first procedure was performed whilecovered under this plan or not.TOBACCO CESSATION BENEFITBenefit Limits apply as stated in the Schedule of Medical Benefits.Coverage under this benefit includes charges for Cessation Services provided by a Licensed Physician,counselor or psychologist including, Tobacco Cessation Remedies.“Tobacco Cessation Remedies” include epidermal nicotine patches, nicotine gum, nicotine tablets andcapsules and any other non-experimental pharmacological compound ordered by a tobacco cessationservice provider for the purpose of inhibiting or reducing the addictive effects of smoking or nicotine.Western Montana Providence Health & Services - SPD 30Group #2000204 - January 1, 2011