Tricare Prime Approval...Bitter Sweet

[Pashion 7]

I was approved by Tricare Prime today for my band. It is a bitter sweet approval because I was hoping to have my surgery done thru Scripps Clinic, but because Prime is considered an *** they are only approving the band if I go to the local Navy Medical Center. I guess I should be happy because at least it was approved on my first try but now I might have to go thru everything all over again at Balboa and I have no idea of what to expect thru them or how long it will take before I actually have the surgery done. With Scripps I could of had it done befoer Nov 11th....Once again I'm playing the waiting game. If any one has had their band done at the San Diego MTF Balboa please let me know what Dr. you used and what I should expect?

[Dave_NW 92]

You may want to challenge them about this. I live up in Washington state, and I had a choice of several Tricare Prime-approved places to have my surgery, including a military facility. I chose a reputable civilan hospital, mainly because it was more convenient for me. San Diego may be a different thing, but I'd think coverages would be the same.

Good luck!

Dave

[Pashion 7]

You may want to challenge them about this. I live up in Washington state, and I had a choice of several Tricare Prime-approved places to have my surgery, including a military facility. I chose a reputable civilan hospital, mainly because it was more convenient for me. San Diego may be a different thing, but I'd think coverages would be the same.

Good luck!

Dave

I knew going into this that if there was a surgeon at the MTF available to do the surgery within the next 30 days of approval that I would be required to go the MTF. I was just hoping that would not happen. I do not know why each Tricare Prime region is so different but they are. I'm just praying that I do not have to go thru a whole lot of changes thru the MTF before they will do the surgery. When I called the MTF today to set up an appointment to meet with a surgeon. The rep told me that he first has to send my auth to the Nurse Practition and then she will fax him a list of surgeons that are available to do the surgery and that I should hear back from him no later than this Monday. He could not tell me what all the MTF requires before they would do the surgery he just stated that the surgeon would give me a list of things to complete before they will set a surgery date. Every time I use the MTF for ER visits I have a bad experience so I am hoping that the surgery center is not the same.

[sleeveInSD 17]

I knew going into this that if there was a surgeon at the MTF available to do the surgery within the next 30 days of approval that I would be required to go the MTF. I was just hoping that would not happen. I do not know why each Tricare Prime region is so different but they are. I'm just praying that I do not have to go thru a whole lot of changes thru the MTF before they will do the surgery. When I called the MTF today to set up an appointment to meet with a surgeon. The rep told me that he first has to send my auth to the Nurse Practition and then she will fax him a list of surgeons that are available to do the surgery and that I should hear back from him no later than this Monday. He could not tell me what all the MTF requires before they would do the surgery he just stated that the surgeon would give me a list of things to complete before they will set a surgery date. Every time I use the MTF for ER visits I have a bad experience so I am hoping that the surgery center is not the same.

Hello there, I am a retired dependent as well and also live in San Diego. I'm just now getting started with my first visit to my pcm being last Thursday 10/27. My pcm is at Scripps Ranch Medical offices. I'm still waitng on my referral to see a bariatric doctor and have a feeling I will be referred to Balboa as well. I don't have experience with their emergency room but my daughter was referred there for some treatment and it went very smoothly. I suppose it depends on the department. One advantage to going to a MTF is you have the option to have the gastric sleeve done there. I am actually undecided at this point and am still doing more research, but from what I understand is that you can only have the sleeve done at a MTF with tri care prime, unless that has recently changed. Also, you may or may not have looked at Baboa's website, but I was just on there and found quite a bit of info about there bariatric center and what they require for surgery. The forms you have to fill out are there to download as well. Good luck with every thing!

[Pashion 7]

Hello there, I am a retired dependent as well and also live in San Diego. I'm just now getting started with my first visit to my pcm being last Thursday 10/27. My pcm is at Scripps Ranch Medical offices. I'm still waitng on my referral to see a bariatric doctor and have a feeling I will be referred to Balboa as well. I don't have experience with their emergency room but my daughter was referred there for some treatment and it went very smoothly. I suppose it depends on the department. One advantage to going to a MTF is you have the option to have the gastric sleeve done there. I am actually undecided at this point and am still doing more research, but from what I understand is that you can only have the sleeve done at a MTF with tri care prime, unless that has recently changed. Also, you may or may not have looked at Baboa's website, but I was just on there and found quite a bit of info about there bariatric center and what they require for surgery. The forms you have to fill out are there to download as well. Good luck with every thing!

Hello Reginamarie,

Thanks for responding, I have been on the bariatric website at Balboa and found it very informational. I already have the forms filled out lol. Also I have spoken with other people who have had their surgeries there and have had very good results. And yes, the more research I do the more I am leaning towards having the sleeve, especially since we may be moving to another state that does not have a MTF and I do not want to have to worry about trying to find a Dr. to do my fills.

My PCM is at the Rancho San Diego Medical Office. Okay so this is how it went for me, Tricare Prime approved me to see the Scripps surgeon for the consult (authorization took about a week), but when it came time to get approval for the actual surgery (which only took 24hrs) Tricare Prime "Approved w/Modifications" meaning that Tricare Prime will only approve the surgery if I have it done at Balboa. If you have Tricare Standard they will give you the choice to have the surgery either at Scripps or Balboa, because standard is like a PPO and Prime is an *** and I have Prime.

With Balboa everything is a waiting game. The issue that I ran into at Balboa is they are short on surgeons. I will not be able to see a surgeon at Balboa for a consult until December 6th and I was approved for the surgery by Tricare Prime on 10/24. The problem is, one surgeon is getting deployed so he is not seeing any more patients another surgeon just got in and she is still in the process of setting up her office, and the other two surgeons are booked. Tricare has a policy that you have to wait 28 days from the date of approval before they will even CONSIDER giving you approval to go to a civilian surgeon.

The other issue is depending on the surgeon you get at Balboa he/she may make you use their own psych, nutritionist, support groups, and do all your blood work over again at their facility even though you already had everything done at Scripps. There is another very nice lady on this forum who had her lap band surgery done at Balboa she stated it took about three months to get all the blood work done. My friend who had the sleeve done at Balboa said she had to wait six months to have the surgery because Balboa was booked and her surgeon wanted her to loose 10-20 lbs before surgery just to prove that she could lose weight...if she could lose weight on her own she would not had needed the sleeve, thats just my opinion.

My advice to you is, if you have Tricare Prime, just cut out the middle man and go directly to Balboa it will save you a lot of time and aggravation because that is where you will end up at anyway.

Good Luck and keep me posted I am curious to see what happens with your approval.

[Ric 89]

Get this done ASAP as I was reading an article yesterday that over $363million was spent on dependants an Retiries having some sort of Bariatric Surgery! With the economy of today and cutting benifits I would not be suprized if Tricare will stop authorizing these type of elective surgeries. If you have noticed Tricare Prime went up already. I have been retired from the Marine Corps for 10 years. I am glad that my surgery was done in June!