Tricare

I am new to all of this.  I have been wanting WLS for a while now but have never attempted to go for it because of my insurance.  My husband, who is in the Army, can get Tricare for the family.  I'm a bit concerned because we are basically getting it to get if for me.  Do any of you think that will cause a glich for me?  Will I have to be on Tricare X amount of time before pursuing WSL?  Also, I don't have any co-morbidities but I have been told on several occassions that I am borderline hypertensive and diabetic.  I have never been tested for sleep apena or anything that may qualify me for WLS via Tricare.   My finaly question, I'm 5'5" and currently weigh 245lbs.  Does that put me over the 200% mark Tricare looks for? I am lost here.  Can anyone clear the clouds for me?

Ok, here it goes for Tricare..... Depending on wether you are prime or standard.                         Tricare Prime, you will need a referral from your Primary Care.                         Tricare Standard, you will just need to find a surgeon that is in network Tricare will not cover Lap Band, only RNY (Gastric Bypass) As far as I know, there is no waiting period. To find out if you are 200 %, Tricare uses the metropolitan weight table.  You say you are 5'5" medium frame is 127 - 141lbs.  Now if you take the minimum of 127 and multiply by 2 you get 254lbs.  So right now you are approximately 9lbs shy of the mark.  But, if you are small boned it will put you in the target zone. Prior to your paperwork being submitted, you will need psyc eval, dietician/nutritionist consult, ekg, testing to rule out peptic ulcer, and you will need to see a pulmonoligist who will most likely require a sleep test.  They will possibly ask for a full panel blood test where they check everything and anything along with a thryoid panel. I hope this helps.  Oh, fyi if you are at or near a military installation that has MTF, then you won't have to go through all these hoops.

Tricare now covers Lap band.  I believe they started covering it in January.  If you have prime just have your PCM put in a referral for you.  I'm going through it now and so far the process has been easy.

are you sure about the 200% thing,, that has been worrying me a lot, i thought it was 127 equalX200 equals 322.58. help me if you can, explain it for me, i have called the insurance company and the girl could not explain it to me, she had no  idea. i have no major disease right now, but my bones in my hips, legs, feet and knees are hurting when i stand and walk. thanks for any help and good luck in your weight loss.

Hi there   , I don't believe getting Tricare for the WLS will cause you any problems at all.  We had Tricare standard then switched to Prime specifically for my WLS because Prime pays 100% whereas standard only pays 75-80%.  My husband is retired, but it works the same regardless if you are retired or active.  If you are near a MTF with a surgeon who does the RNY, you won't need Tricare, but the wait lists are usually really long if you go that route. Tricare does not require any specific testing prior to paperwork submission, such as EKG, psych eval, etc...those tests are requested by each individual surgeon.  Not all surgeons requests those tests, mine didn't.  If your surgeon does request them they will have to be completed before they submit your paperwork to Tricare for approval, but Tricare does not require them for approval.   All they want to know is:  Are you 100lbs. overweight with a co-morb?  OR 200% overweight without a co-morb...that is all they require for approval. I was 5'2" and 232 lbs. when my paperwork was submitted for approval.  I had no diagnosed co-morbs but Tricare approved me based on pain in my weight bearing joints...knees, ankles, and hips.  They did not ask for any documentation.  My surgeon's nurse called me and said Tricare wanted to know if I had any pain in my weight bearing joints, I said yes, and I was approved immediatedly...the nurse had the lady from Tricare on the phone while she was talking to me, that was it.  Make sure you tell your surgeon or PCM any problems you have due to excessive weight...shortness of breath, stress incontinence, pain in your joints...even if its not documented it may help you get approved.  Like I said, they approved me without any documentation at all.  We've had Tricare for over 8 years, my husband has had it for over 20 yrs. and we've never had any trouble with them at all. Good luck to you and feel free to PM me if you have any more questions...we're pros with Tricare insurance and I'm 11 months out from the RNY.

Sorry for not responding sooner. I'm new to this and I have yet to learn how to move through the site.  All of the information you shared is very helpful.  My PCP referred me to a WLS in town.  I am going to take this slow because I want to make sure all my ducks are in a row before I submit a request into Tricare.  My husband is deploying to Iraq a 3rd time and I am shooting for trying to have it done when he is on leave before he goes. 

 

I have Triwest and I was denied GB.  My BMI is 39.6.  I have xrays showing I have degenerative disk disease, high cholestrol ( they say is not co-mobidity) and high blood pressure. I have all the issues you have on your post and the GB dorctor has all the info.  When I called Triwest they said I was not over 100 lbs..I am 5 lbs from 100 lbs.  I am going to appeal. Do you have any other suggestions that might help? or am I just one of those with the bad luck.

Denise-- I am on Tricare standard and was wondering about switching to Prime so I did a search on this board and TA-DA!  There I found tyour message!  I tried reading the Tricare website, but I am unsure if I could just switch and then go to the PCM for referral for the surgery or if there was a waiting period.  I know the surgeon I really would like is NOT a Tricare provider, but for the $$ difference, I could get over it! Any help you could give me?  Thanks! Diana

Hi Diana, glad you found me!  I switched from Tricare standard to prime specifically for my WLS because of the difference in coverage.  If you switch to prime your new coverage will become effective at the first of the following month....so if you switch sometime in June, the prime coverage will begin on July 1st....that's the only waiting period you'll have.  Once the new coverage begins, go to your PCM for the referral.....it can be done online, all they have to do is print out a form, fill it out, than fax it back to tricare....once that's done tricare will either approve or deny your surgery consults....if approved, contact the surgeon you've chosen and get your paperwork done, they'll submit to tricare and then you wait for approval or denial....I was approved in less than 24 hrs. after my surgeon's office submitted my paperwork....you can check it online to see if you've been approved or not before you get the call from your surgeon.  The total bill for my Lap RNY was over $32,000....I paid less than $100 out of pocket...my husband is retired so we have a $12 co-pay...Tricare prime paid everything else.  It is definitely worth it to switch, in my opinion.  Good luck to you and let me know if I can help any other way of if you have more questions....just PM me!