Tricare Prime vs. Tricare Standard

[DaniKLargo 0]

I'm currently on Tricare Prime, and I have a dilemma. I've read the manual and talked to my PCP - but neither had much info about Lapband. My understanding is that Tricare requires a person to be at least 100 pounds overweight, in addition to the BMI and comorbidity requirements. Now I've found out that the Tricare Prime that covers Key West also requires a 6-month supervised weight loss program before anyone can be approved for wls.

I am right at 100 pounds overweight. If I lose any weight at all I will no longer meet the 100-lb requirement. I'm told I can possibly get a waiver, but no guarantees. So instead of wasting 6 months just to be turned down, does anyone know if Tricare Standard has the 6-month requirement? I'd happily pay a co-pay if it would mean less red tape.

I'd really appreciate anyone's Tricare advice - particularly Lapband experiences in the Florida area. I know it's a new procedure for Tricare, and any real-world info would be helpful.

Thanks - Dani

[linda7 0]

DNI, i AM FROM jACKSONVILLE. That's n. Florida. We have Tricare Prime. We are in Ticare South region. I have talked to several people about the requirements for the lapband surgery I have even read it in their mannual and it only sayes the 100 ponuds over limit. Unless they have changed it in the last 60 days. My surgons office even checked into it. I am alsovery close to the 100 pounds. But now that I"ve weighted in I shoul be good to go. But I"m still waiting to be banded.

[Stay_Tuned 0]

Hi there.. I am not in the Fla area.. but here is what my PCP and I discussed about tricare.... 100 pounds overweight with co-morbidities...OR 200% over ideal weight from the metro. life table/chart......Those are the only requirements... I would ask your PCP to refer you to a bariatric surgeon to be evaluated. Once that happens you can go from there with insurance approving or not....

Hope this helps!

I am triwest btw

[ak_gurl05 0]

Hello, sorry to hear that you have to do a 6-month plan. I also have tricare and was worried about the 6-month diet plan. But at orientation they told me that tricare usually does not require it. I totally understand also about being at the 100 pound limit, cause if i loose any weight too i will not quilify. I would just explain to your pcp that you have tried everything and now want to try surgery. Good Luck

Jessica

[Choromom 0]

I was able to get authorization without the 6 month diet thing by being able to show that I had tried and failed with other plans...for as far back as 25 years.

My current dilemma is that hubby retired last weekend, so I'm now on Standard, instead of Prime. Both MD and hospital are Tricare contract, so I'm told they will accept what Tricare pays, but now I have my deductable and co-pay. I think it's going to work anyway, but I would certainly like to have an idea of how much Tricare (Triwest) actually pays, so that I know what my cost share will be? Anyone have any ideas?

[linda7 0]

hello, I'm sorry you are having problems with your Tricare. Your are on standare and sometimes it is easier because you can chose any surgon that will accept tricare and if you are prime you can't. There is a lot of information here about tricare on here. Sorry I can't help you more. Good luck.

[aculberg 0]

Choromom ~ I see youre in Utah, me too, were stationed up at Hill AFB. What surgeon are you working with? I just got my referral to SL Regional with Dr Cottam and Dr Richards. My referral was approved last nt, but when I called the surgeons office today, I couldnt get a hold of them to make an appt!!:wink2: As far as Standard goes, I think you pay up to $1000, thats your max deductible for the year, then they pay everything else. But I'm not 100% on that one, you may wanna call them and ask. I've heard that with a network provider you pay 15% they pay 85%, up to that max of $1000. But check it out, and let me know what docs youre going with! Good luck!

[Choromom 0]

Aculberg!

I'm going to Salt Lake Regional and Drs Cottam and Richards, too! And, yes, it is more than a little difficult to connect with the office! The gal that usually does all of the coordinating stuff is on maternity leave until July.

Have you seen them at all yet? Do you have a preference as to which surgeon?

I've done my initial consult, psych eval, nutritionist, and exercise consults, and had an esophageal scope because of GERD. Just need to get the last few paper hoops done, and the last couple of phone calls connect with the office. (Both docs are taking vacation in June, too, so that complicates it a little more!)

Keep in touch!

[eazes 0]

I'm currently on Tricare Prime, and I have a dilemma. I've read the manual and talked to my PCP - but neither had much info about Lapband. My understanding is that Tricare requires a person to be at least 100 pounds overweight, in addition to the BMI and comorbidity requirements. Now I've found out that the Tricare Prime that covers Key West also requires a 6-month supervised weight loss program before anyone can be approved for wls.

Are you in the Tricare south category? Tricare doesn't require me to do a 6 month supervised diet. I'm glad they didn't. My doc doesn't even require it. Talk to your PCM and see what they say. I know for me I've had documented discussions with my various PCM's about my weight so if you have done the same maybe they could look at that as a way to see that you've been trying to lose weight for a certain amount of time.

[mljalways 1]

I have a surgery date of 11/11 and they are just now submitting to Tricare. No 6 month diet here

[L12 13]

I am in FL with Tricare South also, but have Tricare Reserve Select (basically Standard for Reserve/NG). I don't have the 6 month requirement, although I have run into a few bariatric surgeons who require it regardless of insurance requirements. Sorry I can't tell you more about Prime.

[sharmom 7]

You need the pre aproval with tricare prime. Is there anyway to switch to tricare standard? I am tricare standard and it took 3 days to get approval. So far all I have had to pay is 700.00 my surgery was9/26/08 go to military.com the have some info and you can also call them on the phone they answered many questions for me. Dont give up even if they say no you can re apply

[sharmom 7]

Tri care standard is better for lap band because you do not need all the pre authorizations. I just had surgery 3wks ago and it took 3 days for approval. The insurance lady said standard is way easier than prime. so far I have only had to pay 700.00 out of pocket I even spent the night in the hospital. Dont give up. go to military.com and type in Lap-band it will give you more info

[YngGram 73]

Am I the only nut stuck in VA trying to deal with a surgeons office that is telling me 6 months of supervised weight loss? I am at 240 5'2" I think the BMI is 43. Office says from that standpoint I'm good but need proof of the 6 months. I tried a program 23 years ago! Who keeps stuff that long? TriCare tells me it's not listed as a requirement but of course it is case by case. The surgeons nurse or whoever that called me today was very adimit about that requirement stating she deals with these people all the time and I just wasn't talking to the people she deals with.

[tomatogirl 0]

Am I the only nut stuck in VA trying to deal with a surgeons office that is telling me 6 months of supervised weight loss? I am at 240 5'2" I think the BMI is 43. Office says from that standpoint I'm good but need proof of the 6 months. I tried a program 23 years ago! Who keeps stuff that long? TriCare tells me it's not listed as a requirement but of course it is case by case. The surgeons nurse or whoever that called me today was very adimit about that requirement stating she deals with these people all the time and I just wasn't talking to the people she deals with.

You are probably dealing with the same Tricare lady I did (the one who decides these things for the greater DC area), Pat Nealson. If you want her direct number, I have it. She tried to pull that 6 month diet crap on me at the last minute, but I had a freaking fit because I had already wasted 2 months trying to get an answer, so she accepted my written diet history.