Question:
No surgeons in Network within 50 miles - what next?

Tricare Standard help please!! I am so confused about this insurance. I am new to it and I don't know what to do. I have been told (by a TriCare Representative) that since I live in a remote area and there are no surgeons within a 50 miles radius, that I can go to any surgeon within my Region (which includes five states). She went on to state that TriCare will pay 80% of the total charges (not just allowable charges). Does this sound kosher? I am also confused about the their catastrophic cap. I understand that I do not pay any additional co-payments or deductibles for allowable services received during the remainder of the enrollment or fiscal year, whichever applies, after I have reached my cap. But they state that the cap is for only annual deductibles and co-payments based on CHAMPUS allowable charges, not non-allowable charges. So if I understand this right, If I am charged $45,000 for RNY and TriCare pays 80%, then I get stuck with a bill for $9,000. The cap doesn't count, cause the $9,000 is for non-allowable charges. Please help!!    — paschool (posted on November 27, 2000)

November 27, 2000
Jannn, I think you've been mis-informed. I too have TriCare (Prime). If the military CANNOT provide the medical care you need, they have to cover your medical costs 100% to go to a "civilian" physician. You must obtain a "Non-availablity" certificate from TriCare when they cannot provide the medical services you require. It is only when you CHOOSE to use "civilian" physician over a military physician that you must pay the 20% co-payment. In this case, you are indeed obligated to pay the co-payment. However, most doctors that accept TriCare Insurance also have rates that are closer to the "allowable charges" that TriCare accepts, so that you are not left paying a large sum. Personally, I have choosen a Military doctor approximately 50 miles from my home. He has a wonderful reputation and my out-of-pocket expenses when everything is completed will be $11.45 per day for the hospital stay (approximately 3 days). As far as your pre-op appointments with a nutriontis and a psychologist (sp?), the military would also have to pay for these appointmens if there are no such appointments were you are located. I would suggest that once you find a doctor ask their insurance specialist in the office. She/he will be able to tell you exactly how their claims with TriCare work. Good luck to you!
   — Marnie K.

November 28, 2000
I also have TriCare Prime and I am going through the same thing. I live in RI that doesn't have doctors in the network that do this procedure. So I am going 75 miles (MA) to a doctor that accepts TriCare but isn't in the network. (TriCare wants me to go to MD, but that's not reasonable since there is no family in the area to help me. I would be alone for the procedure and recovery) I submitted a letter today to explain why I chose this doctor and hospital versus going to another state. Hopefully they will understand. From what I understand my charges will be about $12 per day, that I am in the hospital and $12 for my doctor's office visit. I wish you the best of luck with your progress.
   — Dottie D.