Who has Tricare Prime?

[amberakamom 13]

Ok, so I found out tricare prime doesn't cover lap band but I have heard of people with tricare that did have it done. So if you did, what did you do to get them to cover it?

Thanks!

[Randi 0]

amberakamom,

I'm covered by Tricare Prime. I learned yesterday that the Tricare contract is scheduled to be updated in January 2007. I expect at that time the Adjustable Gastric Band will be listed as a covered procedure for those who meet the established criteria. Until that time, TRICARE only covers the procedure on a case-by-case basis and your PCM is the key for TRICARE approval.

[amberakamom 13]

Thanks so much for responding!

[DaDrillSgtsWife 0]

hi amberkamom and randi

Thanks amberkamom for starting this post. I was curious about the same thing. Also thanks randi for the information. I am really prayerful that tricare wakes up. I was just looking into purchasing a policy through an insurance company that approves the surgery. Seeing, this I am hopeful that I won't have to go that route!!! :clap2: Randi PLEASE keep us all posted.

[Randi 0]

I will let you know what happens. I'm hoping to know this coming week whether I'm approved or whether I will have to submit an appeal letter. My surgeon did not submit to TRICARE for approval of the procedure. Instead, my PCM is using the information provided by my surgeon to go in for TRICARE preapproval. From what I understand, if the surgeon submits for the non-covered procedure, it would be denied.

Now, there's nothing saying I won't be denied anyway, but at least my PCM is willing to fight for me and get passed the gatekeepers of the automatic "No" response.

[Randi 0]

Well, Folks,

I'm still waiting to hear from Tricare, but my paperwork has made it past the local gatekeepers and was deferred to Humana for further review. So, hopefully, I'll get some type of updated status before the end of the coming week. We'll see . . .

[DaDrillSgtsWife 0]

Randi,

Thanks for the update. I am prayerful that it works out for you! I can't wait till tricare give the band the same approval it gives rny. that way we won't have to go through all this.

God bless

[minpinmom 2]

At what point do you know if you have been approved or not? Dr. Spiegel in Houston ONLY does Lapband and I just got my referral in the mail saying that Tricare has authorized 5 visits. WTF would I need 5 freakin visits for if they dont let you have the surgery?

WTF

[lanie2006 0]

I have too have Tri Care Prime - I am going the selfpay route. I fly to Mexico on the 27th of August 2006.

[Miper70 0]

I've heard from 2 different surgeons that even when Tricare does start approving lap-band more than likely a lot of the doctors won't accept it because they pay so little. I hope this is not true.

[DaDrillSgtsWife 0]

Miper,

I agree with you, I really hope that isn't the case. I mean they pay so much for bypass on a daily basis. You would think they would be willing to pay the lower price without cutting into the price too much. Also, I have heard that many believe that tricare will start paying for the band real soon since medicare and medicaid started doing it. ALso champus va does it as well. I am just keeping my figures crossed.

[dotofoz 0]

Hi. I was doing some Googling this am on federal health benefits for bariatric surgery in general, and some decent hits came up pertaining to tricare. I don't have the EXACT websites, but you might wanna try that....It SOUNDED like for the RNY, all they had to do was contact pcp and surgery was actually done on base! Check out, http://www.obesityhelp.com that MIGHT have been where it was. When you open up the site, go to upper right corner, hit insurance, and pick "my insurer". It gives a map to select your state and procede from there. Personally it's a good site, but can be cumbersome to navigate thru. I learned alot and got alot of good info. If you've been turned down, have you tried writing to your senator (being that tricare is a federal based program)? I used to work for a federal public affairs office and that would at least get someone's attention. I already have that planned if I get turned down. I know you want the band, but it wouldn't hurt to check it out.....Good Luck!

:eek:

[Randi 0]

Well, Folks,

I'm still waiting to hear from Tricare, but my paperwork has made it past the local gatekeepers and was deferred to Humana for further review. So, hopefully, I'll get some type of updated status before the end of the coming week. We'll see . . .

Well, Folks, as of last month Tricare is still saying "NO" to the adjustable gastric band (lapband), CPT Code 43770. So, I signed up for VA healthcare to see if I can get funded for the procedure. If that doesn't work, I'm going to research which military hospitals are doing the lapband implant to see if I can join one of their programs. As a last resort, I'll consider self-pay.

[Randi 0]

Hey, Folks,

I don't want to seem an alarmist, but I do want to give you some food for thought on Tricare:

Yes, both Medicare and ChampVA now approve lapband. However, Medicare has added another hoop to jump. The facility where you have the surgery performed has to have the "Center of Excellence" designation or Medicare won't pay for the surgery or the fills.

Now, I don't think it's too far of a stretch to assume that Tricare will add this as one of their additional hoops if they do start approving lapband. So, those of you waiting on Tricare to implement lapband as an approved surgical procedure may want to keep tabs on where the nearest Centers of Excellence are located. Here's a link to the current list:

http://www.cms.hhs.gov/MedicareAppro...rder=ascending

If there's currently not a Center of Excellence located near you, don't get discouraged. This list has grown substantially over the last few months and your facility just may not be listed yet. Just give 'em a call and ask where they are in receiving the designation.<!-- / message --><!-- sig -->

[Randi 0]

I've heard from 2 different surgeons that even when Tricare does start approving lap-band more than likely a lot of the doctors won't accept it because they pay so little. I hope this is not true.

Miper,

I kinda had the experience you're speaking of. I went to a well-known surgery group here in San Antonio and was told they were no longer in the Tricare provider network, but they would accept what Tricare would pay as partial payment, but I would still have to pay $7,000 out of pocket.

Because Tricare is an HMO (Health Managed Organization?), the key to using Tricare has always been to use their in-network providers, which means they have agreed to accept what Tricare will pay. This status can change at any time. So, always verify they are still in network before you use them in case the Tricare provider list is not updated.