Tricare - does is, or does it not

mynmann · 02-23-2008, 05:22 PM

My spouse is Army National Gaurd. We just got Tricare (the army health insurance) because we were told it covered Lap-Band®. I went to my seminar today though and was told that they "cover" it but they pay "zero". I'm beyond stressed. I turn 29 this month and have been "obese" for the major part of the last 12 years. Yo-yoing up and down. My BMI is 38 so I was stressed enough about getting approved. Cause Tri-care says you have to be 100 pounds over and I'm 5'6 and 237 pounds.... I don't know if that's 100 over. It's 100 more than what I'd like to way but my healthy weight goes up to the 150's so that would mean I'd be in the 250, not the 230's. Weight gain has never been hard for me though and I can put on 15 pounds if I need to... I'm fighting to keep them off! :) But I must also have a health condition.... otherwise I must weight 350... which is goanna take longer! :) I do have on again off again hypertention. Usually it's just pre-hypertention... but I can stress myself and eat real bad and maybe shoot it up high enough to get approved.... though I could have a stroke too! :) I also have arthritis... but in my shoulder and they say it must be a "weight bearing joint" and at the time I don't walk on my hands... though if it means they pay the $17,400.00 for surgury and not me.... I could. I just have 3 kids and a spouse about to go to war. I want to stop this weight war and get control and get healthy. It just seems like the insurance company is out to kill me before they'll aprove me. I simply can't afford to finance this, it would break my family financially. That would be selfish of me. We only have one car and never get to go on vacations anywhere because we live so payday to payday.... now I'd have to ask my family to give up any and all fun we have money for (for several years) so I can get healthy and thinner. I just can't. Then today they say that they don't think Tricare will even cover it... ugh!

Long story short, does anyone here have or know about Tricare. Do they pay zero on something they cover? Seriously? And do you know if I sound like I stand a chance of getting approved even if they do cover it?

irideaqh · 02-23-2008, 05:47 PM

Tricare does cover LAP-BAND®. Their criteria is 100 lbs over the weight for your height (based on Metropolitan Life Weight charts - you can find it on line if you search for it) with one comorbitity or 200% over weight based on the chart w/ no comorbitity. You have to get a referral from your PCM to a surgeon and then the surgeon gets authorization for the surgery. Once you get the ball rolling Tricare seems to be very quick in approving surgery. Good luck.

mynmann · 02-23-2008, 05:57 PM

I've seen so much after posting this. Everyone is so back and forth about coverage. Are you on Tricare... have you had the surgury? I'd love to find someone who actually had the surgury and had Tricare pay. I don't want to start this and get my hopes up only to be turned down at the last minute due to some insurance loop hole.

minpinmom · 02-23-2008, 06:00 PM

I have Tricare, and had my surgery on Tuesday, I had to pay a $12.00 copay for my first consult with the surgeon, then $11.00 for the hospital stay. Sweet!

No diets, no psych eval, no nutritionist, nothing - if you qualify, they pay at 100%

Your Dr. may be out of network - or doesn't have their facts straight - Tricare is so new at accepting LAP-BAND®, not all the Dr.s know about it.

mynmann · 02-23-2008, 06:07 PM

I love you. You are awesome. I was getting SOOO bummed reading the other threads. This makes me feel so much more hopeful.

mommakatx2 · 02-23-2008, 06:43 PM

Quote:

Originally Posted by mynmann

I've seen so much after posting this. Everyone is so back and forth about coverage. Are you on Tricare... have you had the surgury? I'd love to find someone who actually had the surgury and had Tricare pay. I don't want to start this and get my hopes up only to be turned down at the last minute due to some insurance loop hole.

I'm not sure which threads you're reading but pretty much since Tricare began approving the LAP-BAND®, they are covering it 100% FOR THOSE WHO QUALIFY. Like any other insurance company, they want to make sure they are paying for people who really need it, not just want it.

I am in the same boat as you...my BMI is only (only! ha!) 40.something, but Tricare does not go by BMI...they go by the amount over ideal weight. You are right in saying that if you are 100lbs overweight, then you must have at least two comorbidities. Comorbidities can be a lot of different things, though. Asthma, sleep apnea, hypertension, arthritis, high cholesterol, etc. are just a few of them.

I am still pursuing the LAP-BAND® and I'm waiting for my surgeon to call so that I can make my first appt. I've already been to the seminar, nutrition consult, and psych consult (required by the surgeon, not Tricare).

Good luck to you and keep us posted! I have three kids also and we're facing our third deployment here in about 6 months...so I know how you feel.

minpinmom · 02-23-2008, 06:48 PM

I have a lot of info on my blog - but, let me know if your Dr. says it isn't covered, I can give you the Tricare paper stating its coverage and the codes that it covers. Everything is updated in Tricare's system now - but the Dr.s office seems to be where most of the confusion lies. It was approved on Dec 10th, I started on that day, once I convinced the Dr.s office to call and not just tell me it wasn't covered. It went pretty quickly. Once the paperwork was faxed to Tricare, it was approved in less than a day. You have to STAY ON TOP of your Dr.s office. I called them and Tricare daily to check progress. They were sick of me I am sure.

Rest assured, it is covered, and the easiest insurance their is if you qualify. Please let me know if you have any questions, I am helping a couple of others right now too that have had problems with their Dr.s office. Here is my email address too wendy@beldwinkennels.com

mynmann · 02-23-2008, 11:03 PM

Thank you so much. My email is myndeemann@gmail.com. I'd love to hear more about your experience. I'm hopeful now. I have Asthma... so maybe that will help me. Thanks for the words of encouragement. My family is SOOO sick of hearing me talk about this surgury. My Mom said I must stop "obsessing" about it and I can barely get anyone else to sit still and listen.... it's nice to find others that understand.

mynmann · 02-23-2008, 11:14 PM

I will be reading your blog. I'm very interested in hearing about your journey. I am SOOO jealous of you right now, I want this Lap-band® so bad. I know it won't cure me... but it will help. A little help is all I need. I'll keep you in my thoughts and prayers. I'm hopeful my story will end the same. I hope. Does it hurt bad? I don't mind needles... I donate blood regularly. I do have low iron though... was that a problem for you. I saw something about that in your blog. I have Asthma, I'm hoping that will help my case!

Oh, do you have to have one (1) or two (2) comorbi...things (health problems). I read 2 but I thought it was only one (1). Just want to be sure I have my BP real high (gotta stress out) if I need to. :) I have kids and an Army man leaving for war... so stress isn't hard to come by.

BTW, before we had to move and give up our home so my hubby could get sent over seas to be a super trooper, I had a dog, a Min Pin. Named Anya. I loved her and I miss her bad. I found her a great home, better than I am even, but I miss her and seeing your puppies made me smile.

minpinmom · 02-24-2008, 09:19 AM

Girl, you keep with it, and you WILL be approved. Tricare isn't stressing the details right now. I didn't have any co-morbidities, but I was approved without because I was 200% over the ideal body weight. If you want the link to the Met Life Ideal body weight scale, let me know and I will post it for you. I had asthma as a child and had Sleep Apnea, but had surgery to correct it when I was 18. I was afraid my iron would be low when I did my blood work, I started taking Iron pills a few days before and there were not any problems.

Thank you for being a Military WIFE! I am an Army Brat and an AirForce wife. My hubs has since been medically retired or we would still be in. I love the Military life and miss it tremendously. I will be praying for your hubby over there.

Pain wise, the IV was the worst for me. I HATE needles. After surgery, I didn't even have any pain meds and I am not even taking Tylenol now. I am a bit achy, but not Oh My God I need meds pain. :-) It was uncomfortable, but not horrible. The only thing I wasn't prepared for was that it is hard to burp. I feel a pressure in my tummy and can tell it is pressing up, but can't get out. Then all of a sudden, I feel a little burp come up. So freakin weird.

My family got tired of me talking about this too. I swear I spend almost all of my spare time on the website. It kept my hope alive when I felt I didn't have any. Now, I feel a bit free -er, I don't spend QUITE so much time on here ;-)

As for Min Pins - they are my Life. We don't have children and they are truly our babies. One of the first things I said in the Hospital is - I miss my girls! Min Pins can be so BAD, but when they are good, they are sooo good. :-)

strikeuptheband · 02-24-2008, 03:53 PM

minpinmom,
Do you know if TriCare is for military veterans or is it just for families of military? Back when I was in, it was called Champus..is this the same thing? I want to pursue TriCare since I have heard (mostly from you) that it works. My work's insurance wont touch WLS even though they don't hesitate to increase my rates! And they will be more than glad to pay for my heart attack, stroke or other weight related illness when I get them. Yea I am being snarly! lol Just trying to find an avenue that will help me pay for this. My BMI is about 37 and I have high BP, high chloresterol and borderline diabetic. Also lots of leg, knee, hip joint pain. Do you think I am miserable enough to be considered?? :-)

minpinmom · 02-24-2008, 06:26 PM

It is for Active Duty Members and Family and RETIRED military and family. You have Tricare Standard automatically (comes free with retirement) Tricare Prime you have to pay a small fee a year (I think its around 200 a year, but I can't remember).

I have Prime, and it is wonderful. I would def. check it out to see if you have coverage. What state do you live in and I will post the Tricare link with phone numbers and such for you.

strikeuptheband · 02-24-2008, 07:20 PM

I am not active duty now and did not retire. Got out after about 10 years of service. I know I can hook up with VA. Looks like Tricare won't help me then. Send the link if you will, can't hurt to check it out. I live in Missouri. Thanks,

minpinmom · 02-24-2008, 08:31 PM

You are in Tricare West, here is the link, it looks way different from mine (Tricare South), so I can't tell you where to look once you get there. I have heard that the VA covers this through CHAMPUS - but I don't know for sure.
TriWest Healthcare Alliance

steph_co · 02-24-2008, 10:20 PM

I have heard from a friend that Tricare South will not cover LAP-BAND®. If anybody could expand on that for me...or maybe that would explain to mynmann if you're on Tricare South? My DH is former Army, but I know very little about Tricare.