How/When do you get a pedi on Tricare Prime?

GracieLou Freebush

I assume I'll have to have a pediatrician set up before giving birth since we need to bring LO in frequently those first few months.  How does the process work?

sarah2542

Don't quote me on this, but if I remember correctly, babies are on Tircare Standard for first 60 days, meaning they can be seen by an off base/post doctor within the tricare network. After the 60 days, you can decide to keep them on standard and pay a little out of pocket, or you can switch them to prime and take them to a doctor on base/post. Since our base doesn't have a pediatrican, we decided to keep DD on standard. All well baby checks (8 weeks, 4 mos, 6 mos, 9 mos, 12 mos, etc) are covered 100%. If your baby gets sick and you take them to the doctor, there is a $150 deductible you have to meet and then tricare covers 85% of the cost after that. DD is almost a year old and have taken her to the doctors once (besides her well baby checks). We just got a bill and we owe $63. If you think about it, most non-military people have to pay a $15-$30 co-pay for each visit. It's well worth the out of pocket money, in my opinion, for DD to see a doctor that specifically went to school to work with children than for her to see a family practice doctor on base. Just my personal opinon though. Don't jump all over me!

ladybug8510

DD is on standard, and so far we haven't paid anything.  She hasn't been sick enough for me to take her in, and our on-call nurse is great about answering questions over the phone to avoid visits.  In my mind it is worth it to be on standard so you can pick a pedi, whose style you agree with.  I was also on standard for my pregnancy and was very happy with that as well.  I think it is important to like your doctors or else you aren't going to feel comfortable in their care.

bootsie08

Actually, the majority of newborns are on Prime for the first 60 days. The only exception is if ALL other family members are on Standard.  Since all active duty members must be enrolled in Prime, this is not likely to apply. 

https://www.hnfs.net/bene/enrollment/addFamilyMember/

With DD, it didn't matter whether she was seen at the MTF or by a civilian doctor during those 60 days - all claims were treated as Prime and covered 100%.  If you want to keep LO on Prime after the 60 days, you must fill out the appropriate paperwork or you will automatically be switched to Standard.

ETA:  OP, are you delivering at a civilian or military hospital?  I delivered at a civilian hospital and DD was seen by the pedi's on staff while there.  After that we just called the MTF appointment line and they booked her next appointment for the next week.  I am delivering at a civilian hospital again and DS will again be seen by the hospital pedi's and then the civilian pedi we have an established relationship with will take over his care.  From what I understand, if you deliver at an MTF and choose to have your LO seen at an MTF, they will assist you with making the first appointment before you leave the hospital.  

StarJay

We were told pretty much what Bootsie said. LO will automatically be on Prime for the first 60 days until we confirm or change that coverage. Our MTF does not have OB/maternity care, so I will be delivering downtown. The hospital pedi's will take care of LO there and then as soon as we bring him home, we'll make an appt to take him into one of the base pedi's.

The part I haven't figured out is how to do this if we have difficulty getting the necessary paperwork for DEERS/Tricare enrollment, since I know the base pedi wants to see all LOs w/in the first week they are home.

ETA: My OB told me the hospital here knows that we won't have a specific name for them and fills out their necessary paperwork to refelct the base clinic as LO's primary care after discharge.

lisa&andy

We used the pedi that was on call the day they were born and just stuck with him. They are on Prime those first 60 days, but you have to get them in DEERS within 30 days. The hospital should give you paperwork that counts for their birth certificate and then once you get their SS card you take that in. When we enrolled the kids in Prime, we requested a civilian pedi, we just had to write out why. You can probably research pediatricians in your area and then once your LO is born, request to see that doctor.

Graney

My lil one was born Thanksgiving day at a civi hospital since Great Lakes does not do maternity.  That following monday we went in to base medical, signed her up for DEERS at PSD (they will assign a temp SSN since you won't get one for a few weeks) then went to the Tricare office to enroll her officially in Prime and choose her PCM from the available list.  We then went down to Pediatrics and got her an appt for the next day since the lady down there made us do all that paperwork before she would make us one.  That being said, supposedly if you call and make the appt thru Tricare you can avaoid doing all that running around till after your LO is seen. 

Hope that helps some.  Later, once you receive your LO's SS card you can go in to to get DEERs updated.

GracieLou Freebush

bootsie08:

Actually, the majority of newborns are on Prime for the first 60 days. The only exception is if ALL other family members are on Standard.  Since all active duty members must be enrolled in Prime, this is not likely to apply. 

https://www.hnfs.net/bene/enrollment/addFamilyMember/

With DD, it didn't matter whether she was seen at the MTF or by a civilian doctor during those 60 days - all claims were treated as Prime and covered 100%.  If you want to keep LO on Prime after the 60 days, you must fill out the appropriate paperwork or you will automatically be switched to Standard.

ETA:  OP, are you delivering at a civilian or military hospital?  I delivered at a civilian hospital and DD was seen by the pedi's on staff while there.  After that we just called the MTF appointment line and they booked her next appointment for the next week.  I am delivering at a civilian hospital again and DS will again be seen by the hospital pedi's and then the civilian pedi we have an established relationship with will take over his care.  From what I understand, if you deliver at an MTF and choose to have your LO seen at an MTF, they will assist you with making the first appointment before you leave the hospital.  

I'll be delivering at a civilian hospital.  Sounds like the next step is to research pediatricians to see if I want Prime or Standard coverage for the LO.

This was all very helpful, thanks everyone!

dhardwick1228

what is the difference between standard and prime. we have always had prime. and have mostly been seen at the hospitals except when my kids were my 'foster kids' before they were adopted but they were under california health insurance.

GracieLou Freebush

dhardwick1228:

what is the difference between standard and prime. we have always had prime. and have mostly been seen at the hospitals except when my kids were my 'foster kids' before they were adopted but they were under california health insurance.

My understanding is that Standard allows you to go anywhere, you pay a co-pay for in-network docs and a higher co-pay for out-of-network docs.  Prime requires you to see your Tricare assigned PCM and be referred out for certain things but doesn't require a co-pay.

Correct me if I'm wrong, ladies.