TriCare/TriWest - chance of approval

[hittpants11 18]

I really want this surgery. I have not been to a doctor in almost 4 years because I USED TO have a phobia about it. Pretty sure I have got over that.

So I am about 105 lbs overweight. It makes everything harder. I don't know if I have any pre-existing conditions (high blood pressure/high cholesterol). I have not called to make an appointment yet - I just upgraded from TriCare standard to Prime.

I am very nervous about getting approved. From what I have read on these forums - some sort of "medical paper trail" is necessary. I don't have that.

Does anyone out there have a experience with this?

[Dave_NW 92]

I have Tricare Prime. I was interviewed by my PCM when I asked to be referred to a weight loss surgeon, and I was basically asked about my weight issues over the years. I explained all the things I'd tried, and how I had been unsuccessful keeping weight off. That was good enough, and I got my referral. I was more than 100 pounds over ideal weight for my height, and I had at least one of the co-morbidities Tricare asks for. So I was pre-qualified before being referred.

At the consult I was sent on with the weight loss surgeon, I was asked very specific questions about how much I weighed at this or that age, how long I'd had weight problems, what diets I'd been on, and so forth. Then they did a physical exam, confirmed the BMI and such, and scheduled me for lab work and an Endoscopy. All that was done within two weeks, and they submitted the request to Tricare for me to have surgery. Three days later I was approved. It was literally just that simple. If you have questions, contact Tricare and confirm the current requirements.

Tricare Prime does not require a six-month managed diet, or repeated visits to a Nutritionist, and whatever. They are very specific about what they will and won't pay for. If you are qualified to have surgery, you will be approved. It is very specific. But it all starts with a referral from your PCM. So you should start there.

Good luck!

Dave

[hittpants11 18]

Wow! Thanks for this info. I really appreciate it!

Way to go on the weight loss!

[Susan Michelle 0]

Thank you soooo much! I have tricare prime and just started the process. I talked with my PCP yesterday during a physical and she told me to research surgeons and she would make the referral. I do have one question that you maybe able to help me with. Tricare says that I have to be atleast 100 lbs over the Met Life tables- well I'm currently at 258 & the table says I need to be 163-140ish. Does that mean that in order to be approved I would need to gain five pounds since I am not 100lbs over the top number? How crazy! I think it would almost be easier to gain the 5 lbs than to deal with the worry of not being approved! (I do have the required comorbities- never thought I'd be happy to have high blood pressure).

[ErinMarie 186]

I have TriCare RS and I was 100+ lbs overweight and had NO comorbidities and I was approved with no problems! I also just updated my blog about all the costs of my surgery with my insurance if you want to get a very rough idea of numbers! (link in my signature) Good luck!!

[Dave_NW 92]

Thank you soooo much! I have tricare prime and just started the process. I talked with my PCP yesterday during a physical and she told me to research surgeons and she would make the referral. I do have one question that you maybe able to help me with. Tricare says that I have to be atleast 100 lbs over the Met Life tables- well I'm currently at 258 & the table says I need to be 163-140ish. Does that mean that in order to be approved I would need to gain five pounds since I am not 100lbs over the top number? How crazy! I think it would almost be easier to gain the 5 lbs than to deal with the worry of not being approved! (I do have the required comorbities- never thought I'd be happy to have high blood pressure).

Susan, you may want to contact Tricare directly, and ask them about their current requirements. There was talk about them approving people with a BMI under 40, but I don't know if that happened. If all else fails, you could also become a tiny bit shorter when they measure your height, so your height/weight ratio would be less. If you're shorter, your top weight would be lower, right? Not that I'm saying to fake out the system or anything... <wink wink>

Dave

[Susan Michelle 0]

Thanks for the idea Dave! I'll have to slouch and measure myself to see if that would work... BMI I'm at a 39.5 so I'm SOO close to 40. ugh! THANKS!