Tricare Prime

turtlebutt825 · March 14, 2011

Ok so I'm fairly new to the Army life and Tricare and what not, but I just have a few questions regarding Tricare. (We are stationed at Fort Lewis, WA)

I have an appointment at Madigan to discuss with my Doctor my eligiblity for the lap band on 4/4. I'm 21, 5'11" and 287lbs. Which is 200% overweight, I think. My BMI is 40 and I have no co-morbidities. I have a friend who is in a similar situation and she said they approved her fairly quickly, but she was on the waiting list for like 3 months and now she is taking all these classes and such. My biggest fear is that my Dr. is gonna tell me that I am ridiculous and I don't need the lap band. I have been overweight since I was 8 and obese since I was 13. I have been on every diet that they have ever put out there, with some success on some, but I always gain back everything I lost plus another 15-30lbs. I also have infertility and cycle irregularities due to my weight. I also have a family history of hypertension and heart disease. And my mom has had breast cancer twice. I personally don't have any health issues that I know of, besides the infertility (my husband and I were trying for 15 months before we gave up). I want to lose weight to be able to have a child eventually and to live my life.

What do you think the possibility of Tricare approving me is?

And if I do get approved how long does the process usually take?

Lastly after weight loss does Tricare cover the removal of excess skin if necessary?

Thanks!!

Sarah

Dave_NW · March 14, 2011

Hi Sarah. Welcome to the Forum.

Madigan has the best military surgical center in the Northwest. They'll treat you respectfully, and will give you the answers you're after. They do a lot of band surgeries, plus sleeve and bypass, so they have a lot of experience. You're in good hands there.

The thing with Tricare Prime is all about the referral from your PCM to have surgery, and the request for surgery approval from your surgeon back to Tricare. If you meet the requirements, approval is nearly a slam dunk. Tricare Prime is one of the easiest insurance carriers to get approvals from. But you need to follow their very specific rules. Once you do, surgery happens at whatever rate you want it.

If you find yourself on a long waiting list to have surgery, (which could happen with a military hospital), you may want to do what I did: Go to a Tricare-approved civilian hospital for your surgery. Lap banding is common enough here, you may find using a different surgeon may work better for you. I went to Swedish Hospital in Seattle for my surgery, and I have no complaints. They were great.

The process can be pretty fast, if you jump through the hoops in the right order. My intial consult with Swedish was September 29th, and I was approved for surgery on October 21st. Mutual and holiday scheduling conflicts delayed me actually having my surgery till December 6th, but I could have had it done in late October, if things had worked out better. So it's pretty fast. Madigan may be a bit slower because their staff has a lot of people they're dealing with. You should ask them for a time frame.

Excess skin removal: Tricare doesn't approve cosmetic surgery. But if you dvelop a medical necessity to have the skin removed, such as rashes or infections from the skin being there, I'm told they will pay for the surgery. So it all depends on how carefully you and your surgeon/PCM determine the level of your "medical necessity."

Good luck!

Dave

turtlebutt825 · March 19, 2011

Awesome thank you so much!!

My friend has been on the waiting list since October of last year so she is still going to classes and stuff and probably wont get her surgery until summer, or at least that is what she is telling me. Did you get the referal to Swedish with Tricare Prime? If they can do that I would much rather be able to do it sooner rather than waiting almost a year. I know that seems impatient, but I've been overweight since I was 8 lol, I'm really ready to try to make some forward movement.

This appointment in April seems like it is taking forever... lol

Also do you have to go to Seattle for fills?

ETA:

Did you just go straight to Swedish in Seattle, or did you talk to your PCM first?

Edited March 19, 2011 by Lovin My Soldier

Dave_NW · March 19, 2011

You need to have the referral from your PCM to the weight loss surgeon before you can do anything. I asked for, and got mine directly to Dr. Ross McMahon, who is head of bariatric surgery at Swedish Hospital. Once you have the referral, Swedish requires you to attend one of their free weight loss seminars (they have them a couple nights a week) before making your consult appointment. They do that so you'll know whether you want to have surgery. After the seminar (which I found informative, and only about 90 minutes long) you make the consult appointment.

At the consult, they do a kind of "marathon" thing. I had four appointments back to back on the same day. I met with the psych, a physician, a nutritionist, and the surgeon. I also talked with their Insurance Coordinator, to make sure they had me approved through my insurance. (Tricare Prime is easy, but they're very specific of how they want it handled. Swedish's bariatric insurance coordinator is awesome. She had me vetted in no time.)

After they'd each given their recommendation for me to move forward, I was given a pile of blood work lab slips (they need a zillion tests to make sure things are good for me to have surgery) and an endoscopy appointment. Within two weeks I'd had all the blood work and the endoscopy done. Following that, they submitted to Tricare to approve me for surgery, and I had my approval three working days later. It really was that easy.

The program is ongoing, and after surgery there are scheduled followup appointments. Yes, they also do my fills. I've had three so far, and currently am at 8cc in a 14cc band. The staff is great, and very supportive. I can't say enough good things about them. You should review their website, at swedish.org. You can see the info on the staff. They're easy to work with.

I wonder if your friend who is attending classes is requird to do so because she's doing it at Madigan? Tricare doesn't require classes, but maybe Madigan does? Not sure what that is about. I live north of Seattle, so going to Swedish was actually closer for me than going all the way to Madigan. (If you do go to Swedish, tell them I referred you. They'd like that.)

Hope this helps a bit. Good luck!

Dave

turtlebutt825 · March 20, 2011

Ok yeah definitely!! Yeah I'm pretty sure that Madigan requires all of that. I think I'm gonna just ask for the referal maybe I will schedule the seminar this week, but I will definitely let them know that you referred me

Dave_NW · March 20, 2011

Ok yeah definitely!! Yeah I'm pretty sure that Madigan requires all of that. I think I'm gonna just ask for the referal maybe I will schedule the seminar this week, but I will definitely let them know that you referred me

Good luck with thngs, and if I can help in some way, just let me know. I sent you a PM with more specific info.

Dave