Tricare West

I have read a lot of posts regarding Tricare; however, they are all very old.  Was hoping anyone out there with recent experience dealing with Tricare.  My PCM put in the referral, and that as approved.  What is next?  Is a prior authorization needed or was that already approved with the referral?

The referral is for you to be able to see the Bariatric Surgeon.  The BS will still have to get a prior authorization for your surgery.     General guidelines for approval through Tricare for policies that have bariatric coverage are:

1. You are at least 18 years of age and you have completed bone growth.
2. You were unsuccessful with non-surgical medical treatments for obesity.
   1. You must be able to show that you tried and failed programs such as Jenny Craig. This should include regular doctors visits or other documentation of the program and weigh-ins.
   2. Weight loss medication alone does not qualify as a weight loss program.
3. Your BMI is greater than 40 or:
4. Your BMI is between 35 and 39.9 and you have at least one comorbid.  
   1. These can include diabetes, hypertension, obstructive sleep apnea, cardiovascular disease and/or pulmonary hypertension.

You will also need to have a nutritional class and psychological exam, but those are also required by most surgeons as well.   

Hope this information is helpful! 

~Nik

The best thing to do-- with ANY insurance plan-- is to call customer service and ask. See if they can send you a document with their coverage requirements, and ask if they can outline how they handle the process. They may also be able to tell you which steps, if any, have already been processed.

Prior authorization is needed. Since you have a PCM, I assume you are TRICARE Prime?

You will see the surgeon next, who will submit for insurance approval once you have met all pre-op requirements. TRICARE does not cover the sleeve unless you go on base. Depending on where you live and the facilities available, your local base may exercise Right of First Refusal and your referral may go to an on-base surgeon. 

Eta: tricare.mil has all the info on this.