Does Tricare Prime cover lap band and how do you get the process started?

I work in the medical field as a practice manager and just got a "spring mailer" the other day and yes Tricare is covering them with authorization. You must have certain co-morbidities. Also I am unsure if you are aware of this or not but Humana will only have the contract as of now until 4/2011 and then UHC will take over unless the OIG steps in and changes it. If this happens I doubt seriously that UHC will allow it to continue. Before they have taken over the contracts they presented were cut by 10% just in physician services.

I have Tricare Prime South and it covered my lapband 100%. My PCM sent tricare a request for referral, I went to a seminar, a preop appt. And a preop meeting with my surgeon. From request for referral to surgery took a month. My PCM, surgeon and I stayed on the ball and it was the best decision that I ever made! Good Luck!!

I have Tricare Prime with Triwest and they cover the lap band with prior authorization. I went to my PCM and got the referral. Had the consult with the surgeon and within a few weeks was banded.

Be sure to also have your office visits and fills authorized for coverage, otherwise you are responsible for a co-payment.

You will need to have a co-morbidity to qualify quickly.

Also if you have diabetes, after you have lost the weight, your PCM can refer you to a plastic surgeon for a tummy tuck - so long as the excess skin sometimes gets "rashes" from heat and sweat.

Thanks everyone for your helps. I am making an appointment with my PCM to discuss the process. I have been experiencing severe knee pain for the last year and a half and they just determined I have osteoarthritis.

Im so glad I found this thread :biggrin: I am wondering if anyone has experience specifically with William Beaumont MTF (fort bliss)???? At my last appt, my doc "mentioned" lap band, and I also found out i've had high blood pressure for a while now, and am getting my cholesterol, and thyroid checked and checking my blood sugar level. I think my BMI was 39...............so im fairly sure i qualify. I have a follow up next week, and before I get too excited, I want to know if I have months and months wait, or if it is a fairly expedient process to go through? The doc told me Fort Bliss now does Lap Band and has 2 surgeons...

I am glad that I found this post - I just went to my seminar on Sat and am excited! I also have Tricare so I have been trying to get all the information I can on what they cover.

Heres the info from the tricare policy manual:

Tricare's requirements Gastric Bypass (Surgery for morbid obesity) – Limited Benefit – Gastric bypass, gastric stapling, gastroplasty, and vertical banded gastroplasty may be covered when one of the following conditions are met (view Hospitalization Costs):

The patient is 100 pounds over the ideal weight for height and bone structure and has an associated medical condition, such as diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints.

The patient is 200 percent or more of the ideal weight for height and bone structure, regardless of associated medical conditions. (this is by using the metropolitian weight table.)

I hope this helps! Melissa:thumbup:

thank you!!!!

Hi, I am new to this website but would like to know if you don't mind my asking, what was your bmi. I am trying to get the procedure started and mine is 37.5 but I do take cholesterol medicine and am close to 100 lbs over my ideal weight.

Please tell me what you think.

thanks,

I have Tricare Prime South and it covered my lapband 100%. My PCM sent tricare a request for referral, I went to a seminar, a preop appt. And a preop meeting with my surgeon. From request for referral to surgery took a month. My PCM, surgeon and I stayed on the ball and it was the best decision that I ever made! Good Luck!!

Hi, I am new to this website but would like to know if you don't mind my asking, what was your bmi. I am trying to get the procedure started and mine is 37.5 but I do take cholesterol medicine and am close to 100 lbs over my ideal weight.

Please tell me what you think.

thanks,

Welcome the LapBandTalk! Just an FYI, but you're replying to a thread that is over a year old.

I have Tricare Prime, and they covered my band surgery 100%. In my experience, Tricare is very easy to work with, and they are very clear on what they will or won't pay for. This is from their website:

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Gastric Bypass

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
• Is 200 percent or more over ideal weight for height and bone structure
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity

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Start with the referal from your PCM to a Weight Loss Surgery center that accepts Tricare (or a military hospital that performs the surgery, if that's more convenient.) Discuss your situation with the weight loss surgeon, and see what they tell you. My understanding is that a lot depends on how they submit the request for surgery approval to Tricare. If they agree you fit the program, you should be approved no problem.

Good luck!

Dave

After you have completed all the requirements before you can get your date of surgery

Do you still have to be approved by tricare even if they gave you the referrals for the dr, nutritionist and so forth ?

yes, i have tricare prime. after my pcd referred me for all pre ops, the only thing it doesnt cover is the nutritionist visit. tricare was a smooth ride for me