TriCare Users

[eazes 0]

Anybody get banded with TriCare as their insurance provider? I'm wondering if TriCare had you go through certain steps before they scheduled the surgery date or is it totally up to the doctor they refer you to. Any info would be appreciated.

[obgray 0]

I am using Tricare for my surgery. I have Tricare prime and once I had the referral from the PCM, I was authorized visits with the surgeon to begin the discussions. Then there are criteria that you have to meet in order to obtain the authorization for the surgery. These include 6 months of meeting with your PCM or dietician on weight loss, an EKG, abdominal ultrasound, psych visit, blood work, physical exam, and I think there was something else but I don't have the paper work here with me now. Once all of that was submitted it took about 2 weeks to get the approval for the surgery. My surgery is tomorrow in Washington, DC. I was lucky that the hospital that is doing the surgery is also used to working with Tricare patients, so they knew exactly what was needed, and started the process right from my first visit.

If you need any additional advice or support let me know.

[Stay_Tuned 0]

I have Tricare....I didnt do much with my Tricare PCM.... Tricare only requires that you meet the weight requirements to be approved...100 pound over and 2 co-mobids... or 200% over "normal" weight. All other tests have been required by my Surgeons office...

Here is my journey so far

I went to my PCP for an appt to get my referral on March 23rd.

referral was available next day

My surgeon requires you attend the seminar before seeing her the next available was April 21st

Attended meeting 4-21 and turned in paperwork.... 2 years of medical record and my insurance card.

Approved by Tricare for the surgery on 4-25

My surgeon requires that you see a Psych... Did that on 4-30

Appt at Surgeon's office on 5-5 and at that time we scheduled the surgery for 5-21

I had my preop testing and appts on 5-12 that consisted of EKG, Blood work, chest and abdomin xray, upper GI, meet with anesthesia team and also nutritionist. Then another appt with surgeons PA for a quick physical and review of health and tests performed.

5-19 I have my final appt with the Psych

5-21 SURGERY!!!

[eazes 0]

I spoke with the doctor's nurse that is in my area that is TriCare approved and she told me all the things I'd have to do before I could have the surgery. Now the only hang up is getting ahold of my PCM to get the referral put in. They never seem to have any appointments available.

[gina s. 0]

I'm in the middle of the process with Tricare Prime also. All I had to do was get a referal from my primary, and then they set me up with a surgeon. Tricare did not require me to do anything, all I had to do was what the surgeon required. So I had to go to a seminar, then I had to have a phsych eval, and once they got the results from the phsychiatrist they made an appointment for a consult where I met with dietician, a nurse practitioner, and the business office. Now all I have left is waiting to see if Tricare approves, then they'll schedule the surgery and all I have to do is go in for a pre-op appointment two weeks before surgery. So in my case, it was all the surgeon. Good luck!

[Cadets71 1]

Tricare doesn't require any specific tests, documented dieting history etc. They do require that you meet the weight requirement with co-morbidities or 200% of ideal weight. Any other requirements are specific to your surgeon and they seem to vary somewhat among different medical practices.

Tricare standard just requires an authorization for the surgery. Tricare Prime requires a referral to the surgeon AND an authorization. Generally, I think they are very fast on doing the authorizations. Mine was a one-day turn around.

Here is a link to the policy manual where everything is spelled out. Good Luck to you!!

FALLS CHURCH, VA. - TRICARE beneficiaries whose weight poses a serious health risk now have a new surgical alternative available. For those who medically qualify, TRICARE now covers laparoscopic adjustable gastric banding, also commonly called Lap-Band surgery. Although the TRICARE policy change has only recently been made, coverage is retroactive to February 1st, 2007.

"We at TRICARE are careful to only cover procedures that have been proven safe and effective, and are accepted by the medical community," said Maj. Gen. Elder Granger, deputy director of the TRICARE Management Activity. "We've added this procedure because, for some beneficiaries, it may be the right course of action to preserve their health."

Granger adds that, like gastric bypass, gastric stapling or gastroplasty, Lap-Band surgery is only for those suffering morbid obesity. In medical terms, that means their body weight is 100 pounds over ideal weight for their height and bone structure, and their weight is associated with severe medical conditions known to have higher mortality rates. Body weight that is more than twice the ideal weight for the person's height and bone structure may also indicate morbid obesity.

In addition, TRICARE will cover the surgery if a patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery.

Details of the coverage are available in the TRICARE Policy Manual, which beneficiaries can view online. A search for "morbid obesity" goes directly to the correct section.

[bama_belle 0]

The only thing I was required to do was get a referral from my PCM to go to the surgeon I chose. I also had a referral from my endocrinologist to go see this surgeon, so the PCM was a formality for the insurance.

I am +100 lbs overweight, diabetic, sleep apnea, and a couple other issues, so I met all the criteria, and because my physician requires it, I was able to produce 2+ years of diet history, including the diet my endocrinologist has had me on for the past year, plus my medical history where a former PCM recommended me for gastric bypass and my subsequent refusal to have it (due to someone I know who had complications), so...

I saw the Dr. on 4/7. He sent the paperwork in that week.

Tricare approved me on 4/14.

I found out on 4/21.

They called on 5/12 and scheduled me for 5/29. They had originally planned to schedule me for 5/22, but I have a work thing and had no choice but to put it off one more week. I wanted to cry.

But that's Ok. I have time to prepare (AND I'm already on a planned vacation that week so I don't have to explain a darn thing to a darn soul about where I've been !)

[eazes 0]

The nurse didn't say anything to me about needing to know my history. She just told me I would have to attend 2 seminars (actually going to one next week), see a nutritionist, psych eval, and fitness physiologist. I'm hoping everything goes quickly. I would like to be banded before school starts up again. I know nothing is definite until they actually schedule it but that's what I'm shooting for that is if everything goes my way.

[To be free 1]

I have Tricare and will be banded on June 10th. There were no requirements other than the 100 lbs., comorbities or 200%. I had a problem with my PCM at the Naval Hospital she was not a supporter of the lap band or weight loss surgery, she did however refer me to the bariatric clinic at the Naval Hospital they don't do the lap band there so they referred me out.

Any tests or diets are from the surgeon not Tricare. Tricare is requiring me to have an overnight stay which is ok because I am 1 1/2 hours away.

In conclusion Tricare has been great, surgeons office submitted paperwork on a Friday by Tuesday it was on line approved.

[Keleka 0]

Thanks all for the great info on TriCare. I have TriCare Prime Remote and I couldn't locate an in network Dr. near me. I called my PCP office and spoke to the lady that handles doing the referrals and she told me she would fax TriCare. I was told by TriCare they would find me a Physician to go to. Does anyone know how long this will take. Now that I made up my mind to do the lap banding I am anxious to get the ball rolling!!! Btw... I'm about 275 and 5'3" and only have take a Water pill for blood pressure. With your dealings with TriCare, think this is enough?

[zeama 0]

I have Tricare Prime and made an appt in Feb with the white clinic at Blanchfield and saw my PCP and got a referral to see the surgeon. While I waiting for approval to see the surgeon, I decided to go ahead and call Tricare and see if I was approved yet and able to make my appt. I was glad that I called, because there are 2 Drs that perform bariatric surgery and I had been approved for the Dr that only did gastric bypass, so I was able to get the referral changed to the Dr that covered the lapband.

Tricare has been VERY easy to deal with. I am 100 pounds overweight, plus I have high BP and GERD. The first thing I had to is go to an information class that was held at Gateway Hospital in Clarksville, TN. I also had to have bloodwork done, an EGD, an EKG, an ultrasound of my gallbaldder, a sleep study, go to a support meeting, have a pysch evaluation, and finally go to the Diet & Nutrition class. All I am waiting for now is a surgery date.

I would recommend that once you get your surgeon in place, then schedule everything you can, because I am going on month 4 of starting the whole process and I just finished up this week. The thing that held me up was that the Diet & Nutrition class was only held once a month, and I missed last month's meeting.

[eazes 0]

My doctor put in my referral and called Tricare to see if it's approved or not but I guess it takes longer now. I know when I had my breast reduction it took 2-3 days to be approved. May be it just depends on what the referral is for. I must say I'm very excited and can't wait until I can call the doctor and make my first appointment.

[Keleka 0]

My Drs. office faxed in the referral for a surgeon on Tuesday. I checked the TriCare website under referrals and nothing yet. Hopefully by next week I will see the referral. It's like a watched pot waiting to boil! LOL Thanks again for the info!

[RhondaD 0]

I have Tricare Prime through my husband who is retired Air Force. We live just north of Dallas. I got a referral to the Surgeon on 5/15. Attended the LapBand Seminar at the Surgeons Office on 5/21, scheduled my consultation for today (5/29). Authorization was submitted to Tricare Prime today (5/29) by the Coordinator. Checked the Humana Military website to find out the status of the referral for the Psych Consult and my surgery has already been approved. All within two hours. I'm extremely impressed with the timing.

Does anyone know if Tricare Prime will pay for the nutritionist? I am assuming it will pay for the Psych.

[eazes 0]

I don't know if TriCare will pay for the nutritionist. Do you mean after or before surgery? I know for me the nutritionist and psych visits are included in the referral I have to the surgeon. It is what he requires before he schedules the surgery date. How they do it here in Beaufort is that after the surgery I have a free 6 month membership to the LifeFit program at the hospital here. I can use it if I want to but I already have a gym at my house and I can always see the nutritionist at the naval hospital here. I will utilize the nutrititionist at the LifeFit program because...Hey it's free! Well at least for 6 months after surgery. LOL