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dealing with tricare questions.....


Forum: Trying to Conceive with Medical Assistance

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  #1  
March 8th, 2011, 04:38 PM
*JenJen*'s Avatar impatiently waiting
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Okay, I know some of you have dealt with tricare for MA, so I have some questions. Last time I dealt with an RE on tricare, we were overseas so things were a lot different.

Will my PCM need to refer me to an OBGYN first, or can they refer me direct to an RE? My husband has been seen by a urologist, so we know we have to go to IUI with DS or IVF with ICSI and TESE, but the urologist he saw does not deal with any of that stuff anymore, as he works strictly in the urology clinic at this base.

What did tricare cover as far as testing? I haven't had an HSG in 3 years, so I'm assuming an RE will want to repeat that as far as things go, and all the standard bloodwork as well. Can I get an OBGYN to do any of this before we head to the RE to ensure it will be covered?

Did tricare cover any monitoring during your cycles? We're looking at IUI with DS, so I know they won't cover the IUI or the DS, but will they cover meds, monitoring, etc?

I hate dealing with all this. I really wish tricare covered more, but I'm having a hard time getting answers since my current PCM is a civilian AND a royal PITA to deal with. I'm getting a new PCM any day now and just waiting to get the call that I've got a new PCM so I can get the referral(s) in place.

Thanks for your help!
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  #2  
March 8th, 2011, 05:47 PM
KMH KMH is offline
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Hey, girl! Good to see you back here!

Will my PCM need to refer me to an OBGYN first, or can they refer me direct to an RE? I'm pretty sure that your PCM can refer you directly. You have clear reasons for needing to move on to a specialist, so they should be able to put in the referral for you. It took about a week for the referral to go thru before I could make an appointment with the RE.

What did tricare cover as far as testing? Everything...at least as far as I understand. DH had an SA at a local urologist, and then 3 more specialized tests thru the RE, and they were all covered. I had b/w, ultrasounds, an HSG, we had a post-coital test, and I had a lap...all covered. All testing and diagnostics are supposed to be covered under Tricare, so if they try to say otherwise, I'd fight it!

Did tricare cover any monitoring during your cycles? We're looking at IUI with DS, so I know they won't cover the IUI or the DS, but will they cover meds, monitoring, etc? This is where you kind of have to work the system. I am NOT advocating insurance fraud here or anything, but my RE was very experienced working with Tricare and knew how to get the maximum coverage without breaking any rules.

My only IUIs that were medicated were with Clomid, which Tricare covered (even if they don't, it is only $4 for the generic at Wal-Mart). Tricare wasn't supposed to cover the HCG, but they did. I went thru IVP Care Pharmacy, which has since changed names and is now Walgreens Specialty Pharmacy. Tricare is not supposed to cover any medications associated with IUI or IVF.

My CD3 ultrasound was covered, because it was coded to diagnose any cysts and check to make sure everything was clear for another cycle. I usually only had one ultrasound to check my follies, and my RE only ever charged for one...even if I needed an extra now and then. The IUI and u/s combo was $565 for us.

Once you get that BFP, you will likely have to get another, separate referral to your RE for early pregnancy monitoring. This should cover any bloodwork and ultrasounds that your RE needs to perform. I think I had 6 betas and 4 ultrasounds in the first 9 weeks, and they were all covered.


I hate dealing with all this. I really wish tricare covered more. Amen! I'm sorry that you are dealing with difficult people. I hope that you have the referrals in place soon so you can begin your journey!

I know this is looking ahead more than you might want to, but the great news with Tricare is that the actual birth is covered 110%. I had a c-section, stayed in the hospital 5 days, we had visits from my OB and the pediatrician every day, and DH and I ordered 3 meals/day to our private room, and we never even saw a bill. At least Tricare is good for something

If I didn't answer something or you have other questions, please feel free to ask.
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  #3  
March 8th, 2011, 06:03 PM
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Melissa pretty much covered it. I had to change my PCM today because I wont be able to see her for a while, which means longer to get my referral to the OB/RE. Tricare told me that I had to see the PCM so she could put my referral in to the OB and then the OB would do a referral to a RE. This was just my case but I hate dealing with Tricare and I often get so many different answers :/.

Tricare covered my HSG and I had to pay like $3 for my Clomid because the base we were at didn't carry it. They also covered all bw/US and SA for DH.
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  #4  
March 8th, 2011, 07:11 PM
Kobain's Mommy's Avatar Future A&M Aggies Mommy
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Actually they are REALLY cracking down on the IUI and IVF "farud." They will only pay for testing and meds. They said they'd pay for injectables for me as long as it wasn't for IUI. They are also requesting records from REs to prove there is no IUI or IVF. I had to sign a release from my RE's office when I went back

For IVF it's best to see about getting on the waiting lists for one of the few medical facilities that has reduced IVF. It will still cost around $5000 if you are accepted but that covers start to finish with meds.

Ditto Melissa about pregnancy/birth. The only things I had to pay for was lab work since we are standard and that was $2.50 max. I saw a high risk OB along with a regular OB. Both were covered 100%. They also covered all my ultrasounds. I had a c-section and that was covered 100% as well as my LO's 9 day NICU stay.
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  #5  
March 8th, 2011, 07:40 PM
KMH KMH is offline
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Quote:
Originally Posted by Kobain's Mommy View Post
For IVF it's best to see about getting on the waiting lists for one of the few medical facilities that has reduced IVF. It will still cost around $5000 if you are accepted but that covers start to finish with meds.
Not sure I totally agree with you...depends on your personal situation. We looked into it, but decided to pay out of pocket for our civilian RE.

If you are doing IVF at a military facility, you are going to have to add in the costs of hotels, gas or airfare, meals, missing work, etc. and those things really add up. We still would have saved money doing it at a military facility, but it isn't as simple as a $5k vs. $15k comparison.

Also consider success rates and the relationship you have with your RE. I knew and trusted my RE 1000%, and couldn't imagine starting over with a stranger. It helped that my RE was one of the top 3 in the nation as far as success rates for my age group, but I really felt like he was the best possible person to help us with IVF. I didn't want the "bargain" IVF if it meant a reduced chance at success, because I was at the end of my rope. Plus, with travel, there is the potential for a LOT of extra stress involved if things don't go perfectly according to plan.

It is awesome that there are military facilities that do IVF and the savings is pretty amazing, but it definitely isn't the only option. It just depends on how all of these things add up for each couple.
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  #6  
March 8th, 2011, 08:21 PM
*JenJen*'s Avatar impatiently waiting
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Melissa, thanks for all your detailed answers. I was hoping you'd chime in since I'd gotten some info from you before.

I am truly hoping that clomid is enough for us med-wise, as I had a good response to it last time I took it, and since I O on my own now I might not even need that. There is literally ONE RE in the entire area that tricare covers at all, I'd have ot drive 2.5 hrs to get to the next closest, so I'm hoping that they are very knowledgeable about the system. I'm just very concerned about the costs because we are looking at an extra 500 or more per cycle for DS as well, if we go with IUI. Thankfully if we don't have success this spring/summer in late fall my insurance kicks in through work and while they don't have much infertility coverage, they at least do cover more meds I know.

Based on our issues, there is ZERO chance that we will do IVF with a military facility...we had a consult with one of the top urologists in the military and he said that while the programs can be great, he'd not recommend it at all for us because of needing TESE and other things. We'd rather pay the money out of pocket to be able to go to an RE with a great track record of dealing with these issues if we choose to go that route.

Speaking of looking ahead to the birth...I'm super excited because I found out there is a birth center nearby that tricare covers if we decide to go that route! I'm just so thrilled to have the option, since my other choice is the 45 minute drive to the base hospital.

nicole, that's good to know about the releases...I'll put that on my list to ask the RE about when we get in, just to see if they are up to date on the policies and things.
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  #7  
March 8th, 2011, 08:41 PM
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Well, I went from my PCM to my RE. Tricare paid for 100% of my ultrasounds, HSG, 2 Laparoscopies, more ultraounds and bloodwork than I can count.... and they paid for my follistim (minus $9 copay), Femara, Clomid, Prometrium, Ovidrel, etc! I am very thankful for the good insurance!

Now, that being said, We were NOT canidates for IUI, so we are moving to IVF. We are doing it at Walter Reed Army medical hospital in Washington DC in July. It's about 4,000 for it since as of now we won't be needing ICSI. I am very excited about it though! I wish I could do it with my RE, but we are saving over 10,000 by going to DC, and they have an AMAZING IVF program! My RE said a buddy of his is the main dr over there, and that was a good comfort to know my RE likes the Dr! We are hoping to stay at the fisher house, but if we can't we will stay at one of the AFB in the area. We factor in 1,000 in travel expenses, and 1,000 in lodging. Still come out ahead.
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  #8  
March 9th, 2011, 10:03 AM
Jessie0505's Avatar Finally a Mommy!
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Well the girls pretty much said it..although i had ivf last year and they covered most of my meds for ivf..i think my RE put it in as it wasnt for ivf though..we still had some co pays and had to pay for one medication...as far as the referrals went..i was seeing an RE and when i moved i had to go back to my pcm (at my new base) and get a referral..and they kept asking if we had tried for a year..i had already had 3 surgeries for infertility and that was all covered..all diagnostics and surgical issues that are preventing you or dh from becoming preggo they will cover as far as ivf and iui..they wont cover...we tried getting into the program where you get ivf for like $5 grand..but we didnt get accepted..too many referrals..its really hard to get into..and plus it ended up costing the same at our civilian RE here in Arizona then to try to get to the base and have them do it..and i dont think they would have had the compassion my RE had when it failed for us..they were so overbooked..they werent friendly at all! So ya..your best bet would be to call and make an appt with your PCM they will likely answer any questions you have or call tricare..the rules are always changing..thats the military for ya! LOL! Good luck hun!!
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  #9  
March 9th, 2011, 06:41 PM
~April04~'s Avatar Platinum Supermommy
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Lindsey - We're doing a July cycle at Walter Reed as well how awesome that we'll both be there! Dr. Payson is amazing! Let me know if you have any questions - we cycled there in April 09.



Tricare covered everything for us (clomid, monitoring, all appointments, semen analysis - etc). The only thing they didn't cover was the actual IUI and sperm washing. That was about $200 (around there at least - I don't remember).

We did IVF @ Walter Reed - they have a really good program and very good stats. Dr. Paysen is the best. I know military clinics aren't for everyone - but we had a really good experience.
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