Tricare Prime vs. Tricare Standard

[YngGram 73]

I had to get real into this and finally spoke with a man in the Policy Division of TriCare. He says that they don't require the 6 month thing! Now I know it's the surgeron who is trying to get me to shell out $300 to his office. I think I have found an office that doesn't have this and none of the "extras" for nutrienal classes or Opitfast for pre surgery at another 300.

[Wesley'sgurl29 2]

I have Tricare Reserve Select in the South Region. I was approved within the two months that I had all scheduled consults etc. I was 100lbs overweight with co-morbidities of HTN, Diabetes. It was very easy for me.I think Tricare is one of the better insurances. It has paid 90% to the Dr.I also got my hosp bill and they paid all but 600.00 of the 29,000 bill.

[Choromom 0]

May I offer a quick update on my Tricare Standard experiences?

I had surgery in July. Tricare approval came through fine - in fact, you can see a post from me earlier in the thread of how many TIMES Tricare approved, between hubby's retirement, civilian insurance becoming primary, dropping that insurance because of premium increases, and starting Tricare Standard, when we had Prime.

So, with Standard the hospital tells me what my expected co-pay is, due before surgery. It was $380. Tricare then covered at a much higher rate, which means my co-pay increased, and now, 5 months after the fact, I'm finding that I owe the hospital another $1600! We have a Tricare supplemental insurance, that would have covered this expense and any others had I stayed overnight. But as a same day surgery, the supplemental is probably only going to cover about $400, so I'm paying $1200 to $1300 more than I expected or planned on.

At 40 pounds lighter, I am glad I had the surgery. But, I would have done things differently if I had seen this coming!

The frustration of an expense this large that was not planned on has definately shown me that my 'head hunger' is NOT under control!

By the way, this little development surprised the Tricare service rep assigned as my 'counselor'...she had talked me through every step of the way, but was just as shocked at this as I was.

[mrsmajpaul 0]

HI I too am in Va...NoVa...how did your surgery go? I would love to talk with someone in the area. thanks so much

[grneyedvenus 0]

Hi, Dani. I am not in FL, but I had my surgery done under Tricare Prime (South). They did not require me to do a six month supervised diet UNLESS my surgeon required it. All I had to do was get the referral to the surgeon from my primary provider. Once with the surgeon they evaluated whether or not I qualified and submitted all of the paperwork. I had my surgery six months ago, and at that time Tricare required that I was at least 100#'s overweight with two co-existing morbidities (for me it was narcolepsy and asthma). Alternatively, you had to be at least 150% over your ideal weight with no other problems. (I believe that they now require that you are 200% with no other problems.)

I hope that this helps. Talk to your surgeon and find out what they require. Then go from there.

And a word on the six month diet, just because you're on a supervised diet doesn't mean that you *have* to lose weight. It oly means that you must be able to show compliance and are still unable to lose a *significant* amount of weight on your own. Another surgeon (not my own) even recommended to his patients that they gain a little. (I'm a nurse, so I see several surgeons and hear all of their *advice* regularly.)

Good luck!!!

[katwmn63 0]

sharmom- did you have the surgery before you submitted your claim for reimbursement through tricare standard? i too am tricare standard...every time i call them to ask if i am pre approved...they tell me i don't need preauthorization for the surgery.. i looked on line though andit just states i am in process"

any thoughts?

[Electrawoman 5]

But, I would have done things differently if I had seen this coming!

I have Tricare Standard in the South Region. I am just starting out and would like to know what you would have done differently so I can avoid problems if I decide to get banded. Thanks!

[L12 13]

I have Tricare Standard in the South Region. I am just starting out and would like to know what you would have done differently so I can avoid problems if I decide to get banded. Thanks!

Once I had decided upon the surgery, I would have called Tricare right away to get their list of approved surgeons in my area. Instead, I farted around for a couple of weeks looking for surgeons online; it turned out most of them either didn't accept Tricare or Tricare didn't accept them. Plus I wasn't able to come up with a complete list on my own anyway. Calling Tricare first would have been much quicker and easier.

[Choromom 0]

I just felt like I wasted time trying to decide, and got myself into the insurance issues.

If you don't have major life changes coming up that will affect insurance, then make sure you are ready.

[k-statearmywife 6]

The requirements for Tricare Prime or Standard are the same, (100lbs overweight with comorbities or 200% overweight). The only difference is the avenues you must take to be approved (which doctors, approvals etc.) that are required.

My personal story involves 2 denials through Tricare Prime (Triwest) and after switching to Standard I was approved on the third try in a few days! Blew my mind...

I would like to know more about the copays for Standard patients. I'm considered in the Western region, and I spoke to a TriWest rep about a month ago who told me I would only be responsible for unathorized procedures (which all of mine have been approved by tricare) and $15 per night I stay in the hospital.

But after reading other people's responses of $700+ copays I need to know the truth!

[Choromom 0]

I was Tricare Prime when I started the process to get approval, and make up my mind. We became Standard just before my surgery date, which meant I had deductibles that had not been met. I had talked to Tricare, and was told everything would be covered, except for the $380 deductible payment the hospital wanted before surgery.

Mine was same day...so can't tell you about overnight charges.

When the billing went through, Tricare paid a higher percentage than was expected, which meant my cost share was higher.

I had my surgery in a civilian hospital, by civilian doctors.

I suggest if someone at Tricare tells you all will be covered, that you get the person's name and extension number, and make a note of the day and time you were given the information.

Please know that I really appreciate Tricare, and am grateful for the monetary help that allowed me to have the surgery.

But I've worked enough customer service rep jobs to know that, like it or not, not every rep knows what they are doing. That's true whether it is Tricare, computer support, a cellphone company, or whatever! I've learned it is a good practice to track who tells me what, and when they told me.

Policies change. Costs change, Government funding changes. It is what it is.

[Electrawoman 5]

Good advice. Thank you. Turns out, the surgery center who held the seminar I attended does not take TriCare although the doctor does. So I scratched Dr. Benavides off the list. It doesn't do me much good for him accept TriCare if his center doesn't.

I took your advice and called Tricare today. I too have gotten the runaround from them about other issues so I avoid calls like the plague. Every rep will tell you something different. This gal today couldn't even give me a list of bariatric surgeons. She gave me a list of plastic surgeons!

SO I came back here and started searching for doctors that have previously taken Tricare based on posts from members. I located one within minutes. Dr. Cribbins has nothing but good reviews that I can see and I am scheduled for a seminar with him in about a week. MY dedictible for the year has been met so hopefully they can get me in before the end of December. :wink2: Unless something major happens to convince me otherwise, I am going for it. I will keep the thread up to date with cost information as I get it.

[Choromom 0]

Electra,

Check on your deductible. Tricare's fiscal year is from Oct 1 to Sept 30, so your deductible started over again on the first of October.

[untfluter 3]

Just wanted to comment that I lived in Layton, UT, right down the street from Hill AFB in 1996... loved the area!!

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!!:cursing: 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!

[brat7169 0]

I am with Tricare Standard and my authorization request was submitted on 12/3 (Monday). I am still pending, Tricare indicated it should be approved on Monday. I am worried I won't be approved because I am 100 lbs overweight without any other problems. I really want to get this surgery done and I don't want to go through the appeal process. I didn't have a sleep study done which I probably should have done.

I guess I will know in a few days.