Tricare Prime Questions... - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

applesosaucey · 06-07-2009, 10:42 AM

I'm going to have tricare prime in a few months my husband will be going in active duty in the navy and I want to get the Lap RNY. I'm 5'7 and I'm 280lbs highest being 295lbs. I'm pre diabetic and have severe back problems due to my weight my bmi is 46 and I'm 120lbs overweight. What are my chances of getting approved and what do they requrie to get approved

Mz_Desz · 06-07-2009, 11:36 AM

When I had my wls in '04 my pcm sent a letter to Tricare saying I was on a supervised diet for 6 months & a BMI over 40.

You have to either have a BMI of 35 with co-morbidities (misspelled?) or a BMI over 40.

Thats usually it for Tricare. They normally take the word of your physican. Your physican just have to send everything over correctly.

hexx2003 · 06-07-2009, 05:06 PM

yea prime approved me after one letter from my PCM. Problem was, they werent letting me use my civ doc that i chose. Soo. i dropped prime.. and didnt regret it. But i would talk to your PCM and get the ball rolling. They will send a request and you'll hear something back. Depending on your location which looks like san diego.. they do that at the MIL base there. You may have a longer wait, be limited in procedure to be done or have a diet to follow before considering you. I would get it started now. Portmouth Navel told me 2 years wait, 6 month diet had to be followed. That was Nov 5th or 6th, 2008, I went civilian and had my surgery done Jan 13th, 2009.

Azuree · 06-07-2009, 10:08 PM

I have tricare prime, but I didn't have to go on a 6 month diet (boy am I glad!) I did, however, have to document every diet I had ever been on, and the results, etc. A diagnosis of sleep apnea also helped push the decision in my favor.

Good luck!

shecee34 · 06-07-2009, 10:19 PM

This is cut and pasted from the Tricare Prime Handbook.

Gastric bypass, gastric stapling, or gastroplasty—to include vertical banded
gastroplasty—is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure and
has one of these associated medical conditions: diabetes mellitus, hypertension,
cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory
diseases), hypothalamic disorders, and severe arthritis of the weightbearing joints.
2. The patient is 200 percent or more of the ideal weight for height and bone
structure. An associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because
of complications, requires a second surgery (a takedown).

RWK · 06-18-2009, 08:55 AM

I had my procedure (R-n-Y) on 2 Jun 09. I used Tricare Prime and it was such a smooth process involving the Auths/Approvals. I met the BMI requirement and had Obstructive Sleep Apnea which was one of the qualifying Co- Morbitities. I called them numerous times(This was my first time using Tricare) and they were great and answered all my questions. Overall I would have to say the experience was great.

1 Week Pre-Op: 342
Day of Surgery: 329
1 Week Post-Op: 313

StacyW · 06-29-2009, 12:12 PM

Quote:

Originally Posted by hexx2003

yea prime approved me after one letter from my PCM. Problem was, they werent letting me use my civ doc that i chose. Soo. i dropped prime.. and didnt regret it. .

Hi Heather: I was on Prime, then when i moved to a new place at 7 months, i couldn't find a DR. close by so they let me switch to Standard. I just switched back to prime but I see the list of the surgents is very limited. If I switch back to STandard....how much did you have to pay? I know there is a $1000 max - and i already have about $600 paid into that...so does that mean my bill shouldn't be more than $400 (plus the room charge?). Thanks! Stacy

hexx2003 · 06-29-2009, 12:47 PM

your $1000 catastrophic cap runs from October-October.. so plan accordingly. My whole gastric surgery i paid.. including some labs and xrays.. about $100. So far this year.. with Gastric bypass, then gallbladder removal 4 months later, GYN ultrasounds (to check fertility and lining ~i had PCOS prior to surgery) plus my PCP visits i have put out about $550 all year.. believe it or not.. most of that was the GYN and deductible.. So if you already had $600 in for the year, you will have to pay no more than $400 for the surgery. When i got into it.. i expected to pay the $1000.. which ofcourse was totally worth it! Now, normally if you go off of prime.. you are restricted to returning for a period of 12 months. Keep that in mind as well. I am eligable as of Nov 22nd to return.. but it will depend on what clinic i get assigned too. If I dont like it.. then i will stay on standard. To me, its worth the freedom of getting to see whatever doc you want.. and when you want it.

StacyW · 06-29-2009, 03:39 PM

Heather, thank you so much for the information! I am so anxiouse to get started - from what I understand the process can take a long time: so i am trying get all the information I possibly can to make this a little easier.

hexx2003 · 06-29-2009, 03:46 PM

the time it takes all depends on your practice you go to. Tricare is pretty fast at approving or denying. I was approved in less than 48 hours.