SSM Exclusive Choice anyone?

[Dreamin Again 112]

I have been trying and trying to get information from my insurance company. I was able to find out that they cover bariatric surgery but after reading so many posts on here and other places about problems that come up I would feel much better if I could get a copy of the policy in writing.

I called the number on my insurance card - that lady couldn't help me at all so she gave me a number of someone else to call who couldn't help either....but guess what? She also had a phone number of someone else to call who might be able to help me....I think I went through this process 5 or 6 times before losing patience and giving up for the day. Why does no one have any information about the policy for these procedures?

My husband even went to his HR department yesterday and the lady there just looked at him like he was an alien lol. She had no idea but she would get right on it and make some phone calls....

Surely I am not the first person under this insurance policy that has had or needed one of these procedures? Why is it so difficult to get this information?

If anyone has had SSM Exclusive Choice I would appreciate your input on what you had to go through. So far all I know is that I need to undergo a 5 month physician supervised weight loss program.

Thanks and I am sorry for ranting my first day on the boards

[Jersrose43 837]

Is this it? It's online

http://www.ssmhealth.com/exclusive-choice/benefits/documents/exclusivechoice_summary-plan-description.pdf

[Dreamin Again 112]

Thanks Jersrose for your response. It just states that Bariatric surgery is covered "when the patient meets specific conditions". I would like to know what the "conditions" are. Still waiting to hear back from the ins. co. Thanks again and have a good weekend.

[Jersrose43 837]

Well call and see if they can send you the link to their medical policy on line.

It's a very local plan. Your surgeons office should know the rules

[Dreamin Again 112]

Yes, you would think that would be an easy thing to do wouldn't you? The people at the ins co don't seem to know anything about it. Even my husband's HR dept can't help us find the info. They say they will try to get the information and get back to us.

I have contacted the surgeon's office and am waiting to hear back from them.

Edited June 13, 2014 by Dreamin_Again

[Dreamin Again 112]

Insurance is Exclusive Choice CoreSource (Employer is SSM)

My husband finally got a response from SSM Corporate Benefits who got the information from a representative at DePaul’s Weight Loss Program on Bariatric Surgery:

Here are the conditions that a patient must meet to be eligible for the bariatric surgery:

· Must complete a 5-month weight loss program, either the DePaul HMR program (supervised by a dietitian and surgeon) or a 5-month program with their Primary Care Physician, in which monthly visits are required. This program must be physician-supervised and has to have taken place within the last 2 years.

· The patient’s BMI must be at the following to qualify:

o 35-39 with a co-morbid condition, such as sleep apnea, diabetes or Coronary Artery Disease, or Hypertension (plus must be on 2 additional medications if Hypertension is the only co-morbid condition applicable).

o 40+ - no other conditions necessary

· Complete attached packet and return to individual listed on page 1

· Schedule assessment with nurse, mental health evaluation and dietitian (all-in-one visit)

· Meet with surgeon for consultation

The attached packet is the information to sign up for the free seminar that you can get from the SSM Weight Loss website..

Also I was told that I had a $300 copay and they would pay 90% with $1,000 max out of pocket.

Edited July 5, 2014 by Dreamin Again