My spouse is Army National Gaurd. We just got Tricare (the army health insurance) because we were told it covered Lap-Band. I went to my seminar today though and was told that they "cover" it but they pay "zero". I'm beyond stressed. I turn 29 this month and have been "obese" for the major part of the last 12 years. Yo-yoing up and down. My BMI is 38 so I was stressed enough about getting approved. Cause Tri-care says you have to be 100 pounds over and I'm 5'6 and 237 pounds.... I don't know if that's 100 over. It's 100 more than what I'd like to way but my healthy weight goes up to the 150's so that would mean I'd be in the 250, not the 230's. Weight gain has never been hard for me though and I can put on 15 pounds if I need to... I'm fighting to keep them off! But I must also have a health condition.... otherwise I must weight 350... which is goanna take longer! I do have on again off again hypertention. Usually it's just pre-hypertention... but I can stress myself and eat real bad and maybe shoot it up high enough to get approved.... though I could have a stroke too! I also have arthritis... but in my shoulder and they say it must be a "weight bearing joint" and at the time I don't walk on my hands... though if it means they pay the $17,400.00 for surgury and not me.... I could. I just have 3 kids and a spouse about to go to war. I want to stop this weight war and get control and get healthy. It just seems like the insurance company is out to kill me before they'll aprove me. I simply can't afford to finance this, it would break my family financially. That would be selfish of me. We only have one car and never get to go on vacations anywhere because we live so payday to payday.... now I'd have to ask my family to give up any and all fun we have money for (for several years) so I can get healthy and thinner. I just can't. Then today they say that they don't think Tricare will even cover it... ugh!

Long story short, does anyone here have or know about Tricare. Do they pay zero on something they cover? Seriously? And do you know if I sound like I stand a chance of getting approved even if they do cover it?

Thank You So Much For That Information. I'm Sorry To Hear About Your Friend. I Too, Have Heard Horror Stories On The Gastric Procedure....my Children's Grandmother Passed Away From It. As Well As My Best Friend's Cousin. But, I Do Know 2 Other People That Have Had It Done As Well, & They Are Both Extremely Happy With Their Results & They Both Are In Great Health From It. I Guess It's Pretty Much A Risk You Take With Any Surgery You Have.

Mynmann- I went to my TriCare office and they said lapband is now covered. I was given a copy of the TriCare Policy Manual, which describes the patient as:

1. "The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints."

2. "The patient is 200% or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category."

3. "The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).

"In determining the ideal body weight for morbid obesity using the Metropolitan Life Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the weight range. Payment will be allowed when beneficiaries meet all requirements for morbid obesity surgery, including the ideal weight within the newly determined range."

I'm going to check the TriCare office once again to make sure that they understood that it was Lap-Band that I was referring to, but I clearly told her it was Lap-Band that I was interested in, and she told me that as of December, 2007, it was covered. If I find out differently, I'll try to get back on this via your e-mail address.

One expense that you might not be aware of is that of a dietician/nutritionist. My doctor requires a patient to meet with one before even seeing him. Additionally, you will see one periodically during your weight loss period. Mine will see me on the same day that I see the doctor, who is located an hour away from me in Santa Barbara. My dietician charges $60 for the first visit (it was an hour) and $45 for subsequent visits. TriCare won't pay for those visits because we have a dietician at Vandenburg AFB (central coast Calif). She is willing to work with me, of course at no charge, but she has to get the protocol from the doctor in Santa Barbara because she hasn't handled the bariatric patients before. I'm hopeful that the Santa Barbara dietician and doctor will o.k. that, but if not, the number of visits won't be so many that I can't pay out of pocket.

Mynmann- I went to my TriCare office and they said lapband is now covered. I was given a copy of the TriCare Policy Manual, which describes the patient as:

1. "The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders and severe arthritis of the weight-bearing joints."

2. "The patient is 200% or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category."

3. "The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).

"In determining the ideal body weight for morbid obesity using the Metropolitan Life Table, contractors must apply 100 pounds (or 200%) to both the lower and higher end of the weight range. Payment will be allowed when beneficiaries meet all requirements for morbid obesity surgery, including the ideal weight within the newly determined range."

I'm going to check the TriCare office once again to make sure that they understood that it was Lap-Band that I was referring to, but I clearly told her it was Lap-Band that I was interested in, and she told me that as of December, 2007, it was covered. If I find out differently, I'll try to get back on this via your e-mail address.

One expense that you might not be aware of is that of a dietician/nutritionist. My doctor requires a patient to meet with one before even seeing him. Additionally, you will see one periodically during your weight loss period. Mine will see me on the same day that I see the doctor, who is located an hour away from me in Santa Barbara. My dietician charges $60 for the first visit (it was an hour) and $45 for subsequent visits. TriCare won't pay for those visits because we have a dietician at Vandenburg AFB (central coast Calif). She is willing to work with me, of course at no charge, but she has to get the protocol from the doctor in Santa Barbara because she hasn't handled the bariatric patients before. I'm hopeful that the Santa Barbara dietician and doctor will o.k. that, but if not, the number of visits won't be so many that I can't pay out of pocket.

Don't give up hope.

Thanks for that extra information. Out of pocket expenses for me will be hard being that I have 5 children. They range from 17 - 2 yrs old. My husband is active duty & will be going on deployment in the next couple of months. So, I need to be very careful with our money spending. I need to make note of all the extras that I will need to be paying for that my insurance won't cover. Thanks again!

As a mommy of 5, you must be a wonder woman. Our son has 6, so I know how busy your household must be. The only other extra expenses that I know of are any co-pays that you might have if your doctor wants you to see an off-base doctor for the pre-op tests. If I remember right, there is also a co-pay at the hospital with TriCare Prime. Check to see if your base has any dietician. It could save you that expense if your doctor is willing to work with him/her. Good Luck, Mama-- :wink2:Kathy JB

I'm Tricare South and just got done with my surgery consultation for Lap-Band. That means Tricare approved the surgeon referral, but still waiting on the surgery approval (should only be a day or two). I was given a break down of any expenses Tricare does not cover. In my case that was a $35 for a 10 day supply of Protein shakes for the pre op diet, and $65 for a post op vitamine and supplament kit (don't know how long the kit lasts). Many of the extra services I will require are included in the surgeons fee, including meeting with a neutritionist.

Just a note for those of you seeking the initial approval. My PCM didn't weigh me, just asked my weight. They took my BP and said it was boarderline high. I complained of backpain at night and "potential sleep apnea." The point being that my comorbidites weren't well documented and you don't need to be on deaths door step to get approved. A lot depends on your PCM, if they think you will benefit from the surgery then they will probably make sure that you will get approved in the way they submit their referral.

My blog has my experiances so far.

Thanks so much for the info! Yes, it can be CRAZY with 5! Especially since the last 2 (TWINS) was a double whammy! LOL!

Did you have the procedure done already?

Good luck Emily's Dad!

I'm also in the very beginning stages of trying to get in for the procedure.

I so hope I get approved too!

Thanks mommyof5 and good luck to you too. Its a very exciting thought to picture yourself blubber free isn't it!

I think I've made it through the hard part, which is getting the initial referral. The final approval for surgery is just a check to make sure your surgeon isn't trying to rip off the insurance company (or at least that is what I've been told). I'm saving the celebrating for the official "approved," from Tricare.

Well, I went to my doctor last week & asked about Lapband surgery for me. She checked & I was a candidate for it. So, she gave me a referral for it. Then on Monday I inquired into places for it, I filled out the pre-op questionairre & had to call my doctor back & have her send in my referral to my insurance & now I"m just waiting to hear something. Do you know how long that can take?

You need to get an online account with Tricare, that way you can see your referral go through in real time. Mine normally takes about 4-5 days, depending on how fast YOUR Dr.s office is. As soon as Tricare gets it, it take about 1 day (in my experience). Go to your Tricare West website and there should be some way for you to log in. (on Tricare South, you log in with SS# and then change your login info after that)

I actually had trouble with the website. None of my referrals have showed up there. I'm sure I could just call and get it straightened out, but since they just call me when the referral has gone through, I haven't worried about it.

Tricare actually selected the only surgeon in town for me. I'm not sure how it works if you want to choose your own.

The referral for me only took two days. On the second day I called tricare to check and they said it had just been approved. The following day I called the surgeons office to make my appointment.

I am new to the forum but haven't had too much trouble with Tricare it is the physicans and hospital in the area. We are retired military and live in the upstate of SC. The doctors or should I say insurance person(Tricare in network doctor) that do the lapband in our area did not want to believe that Tricare now covers lapband. Once we got our service rep to talk to them, then they wanted to make sure the hospital would take Tricare (out of network hospital). The doctor's office sent the hospital the information. So we have had to wait approx. three weeks and after trying to get this all straightened out, (we thought) we got a call from the insurance person at the doctor's office telling us the hospital is not going to let me have the surgery there because Tricare does not pay enough. They said the lapband itself costs $3800.00 and Tricare only pays $900.00 and that is not including everything else the hospital charges. Has anyone had any luck getting the lapband done in Tricare South?

I am Tricare South and was banded Feb 19th. I didn't have any problems. My Dr. (Spiegel) in Houston, takes the insurance and so does the hospital he uses. There is a thread I started called The comical amount my Dr. charged my insurance .. . They charged 47,000.00 and were paid about 7,000.00.

You just need to make sure that the Dr. is using a Center of Excellence. It may be worth your time and money to travel to someone who does take it.

You are correct, they cover both

Today I was on the Tricare West website & I looked up coverage for this & this is what I got:

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

Can someone correct me if I'm wrong, but I read here that Tricare covers both surgeries.....Gastric & Lapband????