New/want to learn about lap band

Hello, I am interested in finding out if Tricare will pay for the cost of lap band surgery. My hubby is in the Reserves but is about to be mobilized for deployment in less than 2 weeks :( We were just enrolled into DEERS and I am interested in lap band. From what I'm finding while researching, they will pay for it if it's medically necessary and your BMI is above 40 w/ no other medical conditions. Does this sound right? Also, if they do pay for your surgery, do you have to go to a certain provider/base for the surgery? Lastly, is it done as an outpt or inpt procedure? Thanks so much for any advice. I'm new to this but would like to take advantage of the military benefits that are available to us while my hubby is away. Ally

I didn't mention this, but I am also interested in if/how lap band affects fertility? I was recently diagnosed w/ PCOS (Polycystic ovarian syndrome) and we are going through infertility after having 3 children. PCOS can be reversed by weight loss and I'd be interested in hearing if anyone else has had any experience w/ this. Thanks again. Ally

Ally, As far as I know, Tricare does not cover gastic banding (the Lap Band). Tricare does cover three types of WLS: gastric bypass, gastric stapling, and gastroplasty, including "vertical banded" gastroplasty. Also, what I've seen from Tricare is either 100lbs over your ideal body weight with a co-morbidity or over 200% of your ideal body weight with no co-morbidity. They go by the Metropolitan Life Table to find your ideal body weight. See Chapter 8 of the hand book (what is covered). If you signed up with Tricare when you signed up with DEERS then they should be sending you a letter in the mail telling you who your PCM (Primary Care Manager) is. If you don't want to wait for the letter, you can call Tricare and find out who it is. Get an appointment with your PCM and ask for the surgery. Do you live near a post? Some post hospitals have a baratric program in the MTF, so you won't need Tricare approval. The surgeon in the MTF would approve you (though the wait time, I've seen, can be long). If you don't live near a post then Tricare will assign you a civilian PCM and you can also find a civilian surgeon that is in network ahead of time. (go to your regions website to search for in network providers). Your PCM will do a referral for a consult to a bariatric surgeon. If you've already searched out a surgeon and have confirmed they are a Tricare participating provider, tell your PCM you want to be referred to that surgeon. Hope this helped some. Good luck!

Actually, if you dont live near a post, they wont assign you a PCM at all. If you dont live near a post then you aren't eligible for Tricare Prime so you will have Tricare Standard and if you have standard they dont assign a PCM it's your choice. You can go to any PCM you want, you also dont need a referral to a Surgeon, you can choose as long as they accept tricare. Just wanted to clear that up since I'm 100 percent sure of that since I'm going through it since I live in Colorado 4 hours away from any military Post. Krissy

Maybe it is because my DH is active duty, but I have Tricare Prime and I live in Oregon (he is currently in Iraq) about 3.5 hrs from the closest MTF (up in Fort Lewis). I'm assigned a civilian PCM and had to have a referral for the surgeon. I guess maybe reserves/national guard it is different, automatically going to Tricare Standard? Thanks for clarifying! Andi

Actually, my DH is Active duty as well (Navy) and In Iraq as well. I am 4 hours from a MTF (Colorado Springs... Air Force Academy) and I can see any Dr. I want and Dont have to have a referral and still have the same coverage really. I like being able to choose who I get to go see... Krissy

Krissy, Isn't there some out-of-pocket expenses with Standard though? With Prime you can choose your PCM too, just call them up and as long as the dr is in network, they'll switch you. But yeah, still have to do the referral stuff. I guess if you don't go to the dr alot, and you need to pick your own Dr out of network, Standard would do the job. But for me, with 3 kids, it seems like I'm going to the Dr. monthly if not bi-monthly. And I found a great PCM. (And luckily the surgeon I chose happened to be in-network) So I'll take having to wait the < 24hrs for a referral approval to save a couple hundred $$. Prime works excellent for my family's situation. It is always great to have options!! Thanks, Andi

Tricare will cover lap band but only if you find a doctor at a MTF that does the procedure. Officially, they do not cover if but I know of people who have had it done and Tricare for it because it was done at a MTF. If you go with a different surgery type then you don't have to go through that but for the lap band you do. Raven