Heartbroken and frustrated

saywhut82 · May 2012

So my OB's office put in a request over 3 weeks ago for me to get progesterone shots. I am a high risk pregnancy candidate due to a miscarriage and a live birth at 24.5 weeks. Spoke with Tricare several times, gave them hospital records for the other pregnancies, they said I qualified. Yea!

Get a call today from my doctor's office saying Tricare will cover the shots if I pay $621 up front. I don't understand how on the Tricare website it says they will cover it. Everyone I've spoken to says they will cover it, yet Tricare is asking me to pay money up front...money we don't have...for something that will possibly give my baby a better chance of survival. Hopefully the doctor can come up with another solution...but for right now I am so heartbroken and frustrated at the system right now. I have no idea what to do.

bazeyjane · May 2012

I've gotten the rug ripped out from under me by tricare a few times. If your being seen at a miltary facility usually you dont have to pay anything at all at any visit, but if you are being seen by an "outside" care facility that accepts TriCare as an ensurace than, it has been my expericence, that I pay up front and get reembursed by TriCare as soon as I mailed them a copy of the bill. Thankfully, my family helped me out, and when TriCare gave us the money back I was able to pay my family back. I hope you find a way through this, and I pray for a healthy and happy baby!

ufsandra85 · May 2012

can your doctor give you a prescription and you get them from the base pharmacy? that is what i always do. granted i dont go the shots i do the suppositories. the base will order it for you if they dont have it in stock. also ask your doctor if they will do the suppositories instead and if that will work because those are easy to get. i have had the base order me injections before though and had no cost

ufsandra85 · May 2012

it could also be a mistake on your doctors office part. go to your doctors office and call tricare in front of them and have them talk to the tricare people. i have done that before when they told me i had to pay for my clomid monitoring and it worked

sweetpea2003 · May 2012

Are you talking about the 17-P shots?

I took those with my son's pregnancy and Tricare covered it 100%. I used a mail order pharmacy in Baltimore (we were stationed in Pax River, MD).

For other posters: this is a compound that cannot be made at just an average MTF. There is now a drug called Makena that is FDA regulated and very expensive.

OP, when Makena came on the market the FDA decided to allow compounding pharmacies to continue making 17-P in their "off market" fashion (that had been done for 50+ years). It is MUCH MUCH MUCH cheaper - like $10/dose. So if Tricare is really requiring such a huge co-payment (which I doubt), I would talk to your Peri about getting the 17-P through a smaller compounding pharmacy.

But before you do anything, call Tricare. Make sure you have all pertinant information (doctor, exact name of drug, when they put it in the system as a request). I have a feeling that something is happening wrong - either on the doctor's side or Tricare's side. I have had several friends, one as recently as 6 months ago, do a long course of 17-P without any heartburn from Tricare.

saywhut82 · May 2012

ufsandra85:
can your doctor give you a prescription and you get them from the base pharmacy? that is what i always do. granted i dont go the shots i do the suppositories. the base will order it for you if they dont have it in stock. also ask your doctor if they will do the suppositories instead and if that will work because those are easy to get. i have had the base order me injections before though and had no cost

There is a pharmacy about 20 - 30 minutes from where I live that makes the progesterone for the shots. The doctor's office put in a claim for that option to see if Tricare would cover the shots or if they would do it with me paying a small copay. So I am once again waiting for an answer from Tricare and the OB.

saywhut82 · May 2012

bazeyjane:
I've gotten the rug ripped out from under me by tricare a few times. If your being seen at a miltary facility usually you dont have to pay anything at all at any visit, but if you are being seen by an "outside" care facility that accepts TriCare as an ensurace than, it has been my expericence, that I pay up front and get reembursed by TriCare as soon as I mailed them a copy of the bill. Thankfully, my family helped me out, and when TriCare gave us the money back I was able to pay my family back. I hope you find a way through this, and I pray for a healthy and happy baby!

I was being seen at the Naval hospital for this area but on my 3rd visit (I was 10 weeks along), they told me they could no longer see me because I had standard, not prime. (Didn't know military hospitals could pick and choose which Tricare recipients they wanted to accept). I considered it a blessing because the OB I was seeing did not consider me high risk. She said, "Oh, many women miscarriage in the 1st trimester and your daughter being born early could have been because of numerous things. We would have to evaluate you after 20 weeks to see if you would be considered high risk or not."So I asked around to neighbors and my DD school teachers and one doctor was mentioned several times...the one I am seeing now. As soon as I met her, she made me feel at ease and promised to do whatever needed to be done to make sure both me and the baby were safe this pregnancy.

I wish Tricare would reimburse me....they won't I already asked if I would get my money back and they stated no. So I would much rather go through my other options first, then try to find the money second.

saywhut82 · May 2012

sweetpea2003:
Are you talking about the 17-P shots?

I took those with my son's pregnancy and Tricare covered it 100%. I used a mail order pharmacy in Baltimore (we were stationed in Pax River, MD).

For other posters: this is a compound that cannot be made at just an average MTF. There is now a drug called Makena that is FDA regulated and very expensive.

OP, when Makena came on the market the FDA decided to allow compounding pharmacies to continue making 17-P in their "off market" fashion (that had been done for 50+ years). It is MUCH MUCH MUCH cheaper - like $10/dose. So if Tricare is really requiring such a huge co-payment (which I doubt), I would talk to your Peri about getting the 17-P through a smaller compounding pharmacy.

But before you do anything, call Tricare. Make sure you have all pertinant information (doctor, exact name of drug, when they put it in the system as a request). I have a feeling that something is happening wrong - either on the doctor's side or Tricare's side. I have had several friends, one as recently as 6 months ago, do a long course of 17-P without any heartburn from Tricare.

Sweetpea,

They put in a claim for Makena. Tricare approved but not without me paying the funds upfront. So that is why my OB put in a request for the 17-P shot instead through a pharmacist in Va Beach...approx 20-30 min from my house. They did warn me about a possible co-pay but did say it would not compare to what Tricare is asking me to pay, so it should hopefully be affordable. I have my hope back again. If you were able to take those shots and Tricare covered them, then hopefully I should be able to do the same thing.

Temp76535187505890 · May 2012

I'm really sorry you're going through all this but I hope you get it worked out. As for the hospital choosing who they see...Did you sign up for Standard? If so, then yes, they can choose not to see you. Standard patients are seen on a space available basis. If you're going to Portsmouth Naval then it's no surprise they won't see you since they are very full with Prime beneficiaries.

Lissa832 · May 2012

saywhut82:
bazeyjane:
I've gotten the rug ripped out from under me by tricare a few times. If your being seen at a miltary facility usually you dont have to pay anything at all at any visit, but if you are being seen by an "outside" care facility that accepts TriCare as an ensurace than, it has been my expericence, that I pay up front and get reembursed by TriCare as soon as I mailed them a copy of the bill. Thankfully, my family helped me out, and when TriCare gave us the money back I was able to pay my family back. I hope you find a way through this, and I pray for a healthy and happy baby!

I was being seen at the Naval hospital for this area but on my 3rd visit (I was 10 weeks along), they told me they could no longer see me because I had standard, not prime. (Didn't know military hospitals could pick and choose which Tricare recipients they wanted to accept). I considered it a blessing because the OB I was seeing did not consider me high risk. She said, "Oh, many women miscarriage in the 1st trimester and your daughter being born early could have been because of numerous things. We would have to evaluate you after 20 weeks to see if you would be considered high risk or not."So I asked around to neighbors and my DD school teachers and one doctor was mentioned several times...the one I am seeing now. As soon as I met her, she made me feel at ease and promised to do whatever needed to be done to make sure both me and the baby were safe this pregnancy.
I wish Tricare would reimburse me....they won't I already asked if I would get my money back and they stated no. So I would much rather go through my other options first, then try to find the money second.

Prime takes priority at MTFs. If they have the space, they can accept Standard. I don't see the point of having Standard if you aren't going to be seen by a civilian. IMO,that's kind of the point of haing Standard.

I don't think the m/c puts you at high risk status. The preterm birth should put you HR. I had four m/c and was still not considered high risk.

sweetpea2003 · May 2012

Mackalien13:
I thought that tricare did not cover Makena? I thought they only cover PIO. I know that they didn't cover my progesterone suppositories that my OB prescribed me for PTL.

17-P (generic, mixed at a compounding pharmacy), Makena (FDA regulated 17-P), and PIO are all different things.

I KNOW that Tricare covers 17-P and PIO. Whether they carry the name-brand Makena is something I never faced (since it didn't exist while I was pregnant with DS). But Tricare does carry 17-P to help prevent premature delivery. I know a handful of people who have been on it with zero issue from Tricare.

sweetpea2003 · May 2012

OP, I have a friend who was in the middle of a HR pregnancy (previous PTL and premature birth) when Makena came onto the market. She had to go back and forth a lot with her Perinatologist, the pharmacy, and Tricare to figure out how to get the medication. It was before the FDA decided to allow compounding pharmacies to continue making 17-P. Before they did that, KV had sent cease and desist letters to pharmacies telling them to stop making their cheaper versions. So there were hundreds of pregnant women caught in that limbo with KV, insurance, their doctors, and their pharmacies.

If you want me to ask how it turned out let me know. She did continue the medication, but I'm not sure what the end result with Tricare was.

saywhut82 · May 2012

Well good news! I was able to pick up a 5 week supply of the 17-P shot from a Compounding Pharmacy in Va Beach yesterday. My co-pay was $12 and the DH and I couldn't be happier.

Thanks everyone for the support and advice.

sweetpea2003 · May 2012

saywhut82:

Well good news! I was able to pick up a 5 week supply of the 17-P shot from a Compounding Pharmacy in Va Beach yesterday. My co-pay was $12 and the DH and I couldn't be happier.

Thanks everyone for the support and advice.

Glad it worked out!

Heartbroken and frustrated

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