Question:
Tricare Prime
I need to talk to anyone that has been approved for surgery through TriCare Prime without Comorbiddities. What was your BMI when you were approved??? PLEASE need this for approval. having major Peoblems! — NavyNukeWife (posted on November 28, 2005)
November 28, 2005
I had surgery on 2/11/2005. The only problems I had were a low thyroid and
asthma, which they don't consider co-morbidities. My BMI was 43.9. I
didn't have any problems getting approved. I was approved in 6 days. What
seems to the problem w/ getting approved. If you have any other questions
feel free to e-mail [email protected].
Good Luck,
Esther
— essie13
November 28, 2005
Hello Kylee,
I had surgery on 01/18/05 without comorbidities. My BMI was 47. With
Tricare prime to be considered for surgery you need to be at 200% of you
medically ideal weight to be considered for surgery (exp..if you weigh 250
and you ideal weight is 125, then you are 200% of you ideal weight.) My
ideal weight was 145 and I weighed 299 so I was at 206%. I hope this helps
you. BTW, if you click on my name it will take you to my profile and you
can view my progress and photos. Tiffany
— Tiff's On a Mission
November 28, 2005
yeah, like the last answer..you have to be 200% of your ideal weight. What
state are you in? My tentative surgery date is for jan.4,2006 (wont get
here soon enough for me). email me if you need more info.
[email protected] good luck!
— candymarie3
November 28, 2005
I have been denied twice by Tricare prime. You have to be 200% over ideal
body weight or 100lbs over (based on metropolitan life table) with
comorbidities. YOUR BMI DOESN'T MATTER.
— Sylvia B
November 28, 2005
Hey I live in Louisiana. I started at 310 lbs. I had surgery on 10/20/05.
Tricare Prime approved me in 4 days. I did not have any problems with them
at all. They paid for everything but $25.00. I did not have any
comorbiddities. I laughed at the dr when he ask me about problems. I told
him I was a healthly fat person. Then he laughed. We have a surgeon here on
the base where I live that does rny. But he only does it open. So I got him
to refer me off base and I had the surgery the next month. Good luck to
you. If you have any questions or need some help with anything email me!!!.
[email protected] Take care. Mary T
— Mary T.
November 29, 2005
TriCare requirements (the last time I heard): 100 pounds or more over your
ideal weight (this can be waived with certain comorbidities); 6 months of
doctor supervised diet; 2 comorbidities (and I believe this can include
family history). Good luck. Carmen
— kccjer
November 29, 2005
When I was approved your BMI is what mattered (over 35 BMI with
comorbidities) or over 40 BMI without comorbidities. However, if I am not
mistaken they don't look at BMI anymore. I was 42 BMI and 257lbs at
5'4" on my day of surgery (1/19/05)! HTH! I also elected to have my
surgery on-post instead of waiting for an off-post provider.
— MagickalMom
November 29, 2005
My BMI was right at 40 with no co-morbidities, but a very well established
history of physician-supervised attemps at weight loss over the past
decade.
At the time, we were posted in Hampton Roads, Virginia. All Prime
candidates were being funneled through Portsmouth Naval Medical Center,
which has a 2 1/2 year wait list. So, I petitioned the clinic director at
Ft. Eustis (we're Army -- you have to petition the folks who hold your
"money"), requesting to be allowed to go an outside provider
(Weight Loss Surgery Centers of Hampton Roads). I was denied.
After doing a LOT of research, I dropped down to TRICARE Standard. I chose
to pay for my psych evaluation out-of-pocket (about $250) because I didn't
want to wait three more months for an available TRICARE Standard psych
consult appointment. (Had I chosen to wait, the consult either would have
been free, or just 20% of the TRICARE approved invoice.) I also paid the
surgeon's program fee (about $500), again, because I chose not to wait any
longer than I'd already waited. I had a surgery date within three weeks of
my psych evaluation!
My hospital bill was just over $18,000. Of this, I paid $35! Post-op, I've
paid an additional $100 or so out-of-pocket for labs and testing. You
should know that all post-op labwork can be done at your closest Military
Treatment Facility (MTF) at no additional charge; all you need are doctor's
orders.
I fear that TRICARE soon will begin to clamp down on folks who drop to
Standard in order to get this surgery. If you're inclined to do so, don't
wait too long! Now, instead of being on a very lonnnnnnnnnng waiting list,
I'm nearly four months post-op and down 66 pounds! Compared to the
aggravation of dealing with Prime, my out-of-pocket expenses have been
negligible. It was worth every single penny to be able to celebrate my new
"Birth Day" on August 2nd. Do the research! It may prove to be a
great alternative for you, as well. Good luck!
— homefires
November 29, 2005
— candymarie3
November 29, 2005
Initially, I was told by the nurses at the naval hospital, that you need a
referral from your Primary care physician for the surgery. That is the most
important. I was told by the case managers for bariatric surgery ( Tricare
Prime), that you need to be at leat 100 pounds and up, over your ideal
weight for your height and have a high BMI( not within normal limits for
your height and weight). As well as show a history of all that you have
tried in the past to lose weight.That is without the comorbiddidities.
Although, I do have comorbiddities that assisted the decision, I was told
that those were the requirements when you have no other symptoms. At the
time I was initially referred, my only problem was chronic low back pain
because of my chest size. I am 280pds at 5 ft 4 inches, with a BMI of 47.
— Ariana V.
November 30, 2005
I had a BMI of 45.7 without any comorbiddities. I don't take any medication
what so ever. I have three kids 3 1 1/2 and 4 mos old. I have one more
meeting next week before they set the date for my surgery.
— Kimberly Uqdah
December 1, 2005
Hi I'm going through the same problem with tricare prime I was denial the
first time. Now I am appealing I just sent in my appeal letter today from
the doctor and I. I was not 100 lbs. over the ideal wt. at time of review
now that I am I resubmit. At first I thought tricare approval with bmi
over 40 but they don't like the others written in previous letters is
correct. Please pray I get approve this time. if you have any questions
email me at [email protected] I am going through the same case like you.
— rjackson
December 1, 2005
if you are able to go to Madigan Army Medical Center in Washington State
(253-968-1110.)Get an appointment with a primary care provider to get a
refferal to general surgery. The procedure RGB preformed open or
laproscopically is relativally easy to get an approval. Best wishes
— hdpearl
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