If you’re considering bariatric surgery, understanding what your health plan covers can help you avoid delays and unexpected costs. UMR is a third-party administrator for UnitedHealthcare that handles claims and coverage decisions for a wide range of employer-sponsored health plans. UMR plans may cover bariatric surgery when specific medical criteria are met and no plan-specific exclusions apply. Each request is reviewed individually, and approval is based on both the medical necessity of the procedure and the specific language in your benefit plan documents.
Understanding UMR's Role
UMR operates as a third-party administrator for many employer-sponsored health plans. They don’t provide insurance directly. Instead, UMR manages health plans for employers, processes claims, and handles customer service. Your actual insurance coverage comes from your employer, while UMR administers the plan. Each plan type has different rules for coverage and out-of-pocket costs.
Does UMR Cover Weight Loss Surgery?
According to UnitedHealthcare’s medical policy, certain uses of bariatric surgery are considered unproven and may not be covered. It’s essential to review your specific plan language because UMR follows the coverage terms outlined in your benefit document.
Factors Influencing UMR Coverage Decisions
UMR's coverage decisions hinge on several key factors:
- Medical Necessity: UMR assesses whether the surgery is medically necessary. Key considerations include:
- Body Mass Index (BMI): A high BMI (generally 40 or above, or 35 or above with related health issues) significantly increases the likelihood of approval. (BMI is a measure of body fat based on height and weight.)
- Comorbidities: The presence of obesity-related health problems, such as type 2 diabetes, sleep apnea, or uncontrolled high blood pressure, strengthens the case for medical necessity.
- Prior Weight Loss Attempts: UMR typically requires documented efforts to lose weight through diet and exercise before considering surgery.
- Pre-Authorization Requirements: Pre-authorization is mandatory. This involves:
- Completing forms: Accurately filling out UMR's pre-authorization forms.
- Providing medical documentation: Submitting comprehensive medical records, including BMI, details of previous weight loss attempts, and documentation of comorbidities, as supported by your physician.
- Contacting UMR: Reaching out to UMR's benefits department for guidance and clarification on the process.
- Specific Plan Details: Coverage varies significantly depending on your specific UMR health insurance plan. Carefully review your plan documents for detailed information regarding bariatric surgery coverage. Contacting UMR directly to clarify any ambiguities is recommended.
- Using In-Network Providers: Choosing in-network providers (doctors and facilities) is crucial for maximizing coverage and minimizing out-of-pocket costs.
EWTF and UHC Network
The Plan has contracted with the UnitedHealthcare Choice Plus Network (UHC). When you and your family first become eligible in the Plan, you will receive information and an EWTF Benefit Card that identifies you as a network member. You will need to use this card to receive network health care services and prescription drugs. Your UHC Group Number is 76-416098. Always identify yourself as an EWTF participant covered by the UHC network by showing your EWTF Benefit Card to any doctor, pharmacy or other (non-dental) provider you visit. For dental benefits, you will receive a separate card that identifies you as a member of United Concordia’s dental network.
Read also: Understanding BCBS Weight Loss Benefits
Bariatric Resource Services (BRS)
UnitedHealthcare’s Bariatric Resource Services (BRS) administers this program. BRS is a surgical weight loss solution for those individuals who qualify clinically for bariatric surgery. Specialized nurses provide support through all stages of the weight loss surgery process. The program is dedicated to providing support both before and after surgery. Nurses help with support in preparation for surgery, information and education important in the selection of a bariatric surgery program, and post-surgery and lifestyle management. Nurses can provide information on the nation’s leading obesity surgery centers, known as Centers of Excellence (COE). All authorization for, information about and enrollment for bariatric surgery must be initiated through the BRS Program. The benefit provides for one (1) surgery per lifetime. The all-inclusive maximum lifetime benefit relating to this procedure is $100,000. This includes benefits paid at the normal coverage rate for the surgery plus all procedures and pre- and post-operative expenses but does not include services resulting from complications due to the surgery.
Step-by-Step Action Plan
Follow these steps to determine coverage and navigate the process efficiently:
- Review Your Plan Documents: Thoroughly review your UMR plan's details regarding bariatric surgery coverage. Note any specific requirements or limitations.
- Consult Your Doctor: Discuss weight-loss surgery options with your physician. They'll assess your eligibility and provide the necessary medical documentation.
- Gather Required Documentation: Compile all relevant medical records, including BMI, history of weight loss attempts, and documentation of any related health conditions.
- Complete Pre-Authorization: Complete UMR's pre-authorization forms accurately and submit them with all required medical documentation. Use UMR's preferred submission method.
- Follow Up: Track your pre-authorization request's status. If necessary, contact UMR to inquire about its progress. Don't hesitate to call; persistence helps.
- Understand Costs: Once a decision is made, obtain a detailed cost breakdown to understand your financial responsibility.
Hospitalization and Pre-Admission Review
If you are going to be hospitalized, call UMR at 1-866-494-4502 to confirm your hospital stay benefits to make sure your expenses are covered to the fullest extent possible. Covered Hospital expenses are paid at 100% of the allowance for expenses up to the first $7,000 per spell of illness. After that, covered hospital expenses are paid at 80% of the allowance. A part of the Fund’s agreement with UHC is the “utilization” or “pre-admission” review program. When your doctor schedules a hospitalization for you, the doctor or the hospital will call UHC for information about benefits and eligibility. The UHC Case Management Program is designed to ensure that in-patient and post-hospital services are covered to the full extent allowed under the Plan. This will help minimize your out-of-pocket expenses and will allow you to take advantage of any discounts offered.
Second Surgical Opinion
To help eliminate unnecessary surgery, you may wish to obtain a second surgical opinion before undergoing elective (non-emergency) surgery. The Plan pays the full cost of obtaining a second surgical opinion. If the second opinion is the same as your surgeon’s, you will have added peace of mind. If the consultant advises you against the operation, you may obtain a third opinion. Regardless of the outcome, if you still want to proceed with the surgery, you are free to do so.
Navigating Prescription Drug Coverage for Weight Loss
UMR’s prescription drug coverage varies significantly depending on your specific plan. Most UMR plans use a tiered formulary system for prescription drugs. A Drug List, or Formulary, is a list of prescription drugs covered by your plan. Check your specific plan details to understand which tier any weight loss medication might fall under. Many UMR plans also require prior authorization for certain medications (especially newer or more expensive drugs).
Read also: Navigating BCBS for Bariatric Surgery
Weight Loss Medications in 2025
The weight loss medication landscape has transformed significantly in recent years. In 2025, several FDA-approved weight loss medications exist for individuals struggling with obesity or weight-related health issues. The most widely prescribed weight loss drugs include semaglutide (Wegovy), tirzepatide (Zepbound), and liraglutide (Saxenda). These medications belong to a class called GLP-1 receptor agonists, originally developed for diabetes management. Semaglutide has produced impressive results in clinical trials.
These medications can be highly effective, but they are not magic pills. The FDA approves these drugs for use in combination with diet and exercise. Side effects remain an important consideration. Common issues include nausea, vomiting, and diarrhea, especially when starting treatment. These symptoms often decrease over time. Long-term safety data continues to emerge for newer medications like tirzepatide.
Cost plays a significant role for many patients considering weight loss medications. Without insurance coverage, these drugs can become prohibitively expensive. Insurance coverage varies widely. Some plans may cover these medications with prior authorization, while others exclude them entirely. For those without coverage, manufacturer discount programs can sometimes reduce costs.
UMR Coverage for Weight Loss Medications
UMR’s coverage for weight loss medications depends on the specific plan. As a third-party administrator, UMR follows the guidelines set by each employer’s chosen health plan. In 2025, many UMR-administered plans offer coverage for FDA-approved weight loss medications, but with strict criteria. Coverage often limits to patients with a BMI of 30 or higher (or 27+ with weight-related comorbidities). UMR plans almost always require prior authorization for weight loss medications. This process involves your healthcare provider submitting detailed medical information to justify the necessity of the medication. The prior authorization process often takes 3-5 business days. Even with coverage, out-of-pocket costs for weight loss medications can be substantial. For example, a Tier 3 or 4 medication might require a 30-50% coinsurance payment. Some UMR plans implement step therapy, which requires patients to try less expensive options first.
Understanding Your Financial Responsibility
Your Plan provides comprehensive medical coverage for you and your eligible dependents. After you meet your annual deductible, most covered services are paid at 80% of the allowance. Generally, you’re responsible for paying the other 20% of the allowance-your Patient’s Responsibility. However, effective January 1, 2022, your Patient’s Responsibility for No Surprises Services will be determined based on the Qualifying Payment Amount. If you visit a non-UHC provider, you may be responsible for additional expenses as well, including any amount billed by the provider that exceeds the allowance (balance billing), unless the non-UHC provider’s services are No Surprises Services. If you receive services from a non-UHC provider that are not No Surprises Services but the services were provided under circumstances in which you did not have an opportunity to determine, and were not aware of, the provider’s status as a non-UHC provider prior to receiving the services, then the Plan will treat the billed amount as the allowance and will pay 80% of such allowance.
Read also: Qualifying for Medicaid Surgery
For example: Let’s say David has to go to the doctor to receive treatment that does not qualify as a No Surprises Service. The Plan has determined that the allowance for this service is $200 per visit, both in-network and out-of-network.
The Plan limits the amount of eligible expenses you have to pay each year. Once you have provided written proof to the Fund Office that you have paid the out-of-pocket maximum of $8,000 per family in a calendar year, EWTF will pay 100% up to the allowance of your eligible expenses for the rest of the calendar year.
Teladoc
In addition to the in-person medical visit coverage described in this Section, Participants and Dependents also have unlimited, toll-free access or web-based video access to a licensed physician for medical and behavioral health consultations and health information services through Teladoc. You also may download Teladoc’s secure video-based app on your smartphone, desktop or tablet.
Additional UMR Plan Benefits
UMR plans often include a range of benefits to support overall health and well-being.
Disease Management Program
The Plan provides a Disease Management program to help you and your dependents better manage certain chronic conditions in order to live a healthier life. The Disease Management Program starts with an outreach from the Fund’s disease management provider. Participating in the Disease Management program is completely free, voluntary and confidential. Effective May 1, 2022, the Fund will provide disease management services relating to hypertension through Hello Heart. Hello Heart is a provider that specializes in helping retirees, participants and adult dependents (age 18 and over) reduce blood pressure levels and improve heart health. Eligible participants and dependents who participate in the Hello Heart program will receive a blood pressure monitor to track blood pressure levels and will have access to the Hello Heart smartphone application, which provides various tracking tools and resources to help improve heart health.
Annual Physical Exam
You and your spouse are eligible for an annual physical exam. This annual exam, and any routine laboratory work conducted during such annual exam, will be covered at 100% with no cost sharing or deductible. NOTE: Medicare-eligible retirees and their Medicare-eligible spouses are entitled to the Routine Physical Exam benefit only if the services are covered by Medicare. The Routine Physical Exam also includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). Benefits for this vaccine are paid at 80% of the allowance and are not subject to the annual deductible. Your eligible children are covered under this Plan for regular wellness visits and examinations. Your benefit includes the required childhood immunizations.
Maternity Care
Benefits for gynecological and maternity care are payable on the same basis as expenses resulting from an illness. After you have satisfied your annual deductible, covered charges made by a surgeon or a physician are payable at 80% of the allowance. If you have participated in the free “Healthy Pregnancy Program” offered through UHC, benefits are payable at 85% (rather than 80%) of the allowance for delivery charges by the obstetrician.
UHC provides a prenatal education and information program to all EWTF members and spouses. The objective of this program is to promote good health for mother and child, and to reduce the incidence and severity of Neonatal Intensive Care Unit needs by identifying high-risk pregnancies and enrolling members into specialized obstetrical case management.
Maternity care expenses for a member or the member’s spouse can include emergency care, charges by physicians and surgeons in or out of the hospital, assistants or co-surgeons, and anesthesiologist’s charges. The first $7,000 of eligible expenses for room and board and other hospital servicesare paid in full for both the covered mother and newborn child (100% of the allowance, no deductible applies). For expenses in excess of $7,000, the plan will pay 80% of the allowance. You must notify the Fund office and enroll your newborn in the Plan within 30 days from birth. The physician’s charges are paid at 80% of the allowance after you’ve satisfied your annual deductible. The Plan pays 80% of the allowance for obstetrical services for delivery at home by a midwife. The midwife must be a certified nurse, work through a medically directed service organization and be under the direct supervision of a board certified Obstetrician-Gynecologist throughout pre-natal care, delivery, and during postpartum care.
Pregnant participants who are not able to work as a direct result of their pregnancy during any part of the last 13 weeks of their pregnancy will be eligible to receive a weekly benefit equal to the lesser of: (i) 50% of their gross weekly wages based on a 40 hour work week; or (ii) $1,000, for up to 13 weeks. This benefit is payable only if the participant is not receiving a disability benefit or paid leave benefit from any other source. During any period in which a participant is receiving this pregnancy leave benefit, her hours bank will be frozen, meaning there will be no additions or subtractions to the hours bank during this time. However, the participant will receive hours credit solely for the purpose of maintaining eligibility during the pregnancy leave benefit period.
Home Health Care
If you or your dependents require care in a nursing home, a hospice, or care in your home from a registered nurse or licensed practical nurse, the Plan will pay a percentage of covered costs when this type of care is required. The Plan covers expenses for home health care instead of hospitalization or beginning within 24 hours after discharge from a hospital confinement. The Plan will pay 80% of the allowance for covered home health care visits by a registered nurse or licensed practical nurse, after you’ve met your annual deductible. When combined with hospital expenses for the same spell of illness, covered nursing home expenses are payable at 100% of the allowance up to the maximum benefit of $7,000. The Plan pays 100% of the allowance for hospice care in a pre-approved facility or by an approved hospice care provider for in-home care.
Durable Medical Equipment (DME)
Durable medical equipment (DME) is reusable medical equipment such as walkers, wheelchairs, or hospital beds. In general, DME is covered at 80% of the allowance. DME must be medically appropriate and directly related to the treatment of the patient’s particular illness or injury. Limitations may exist on the rental of some DME.
Alternative Financing Options
If UMR's coverage is insufficient or denied, consider these alternatives:
- Medical Loans: Explore medical loans specifically designed for healthcare expenses. Shop around and compare interest rates and terms.
- Payment Plans: Discuss payment plans with your surgeon's office or the hospital. They may offer flexible payment options.