Tricare and Referrals — The Bump
Military Families

Tricare and Referrals

Well I went and saw my new PCM (we just got to Japan the end of April) and I told him about how far we got with our fertility workup and what our next steps would have been had we stayed in San Diego. I know fertility treatment is not available at the Naval Hospital here in Yokosuka, so we will have to see a doctor out in town, which is the reason for my initial appointment with my PCM (to get a referral). He said that I need a referral to a gynecologist in the hospital first and once they go over my history then they can write me a referral for someone out in town...which I know will end up taking months.

When I told DH this he is actually starting to show signs of stress and frustration now which is not like him at all. This is exactly what I didn't want to happen after we moved to another duty station...starting over with testing from the start or having to "prove" our history with our past RE with the hospital here on base even though it's all there in black and white in my medical record.

DH asked why we couldn't just skip the referral process and go out and find someone on our own since we know we will be paying for most if not all of the treatment we receive from a fertility specialist out in town? From what I know to be true, if we were to get pregnant by a doctor out in town without Tricare's authorization to see them in the first place, can't that come back on us and Tricare refuse prenatal care to us?

I may be way off here but I thought there was a reason we had to follow the referral process on base but I just need a better way of explaining it to my husband. TIA!

TTC our first Navy baby! Me:27 DH:30, together since 8/2003, Married on 7/2006
9/26/10 stopped BCP and started TTC.
9/2011 referred to RE. All blood work normal and DH's SA=normal results
11/2011 HSG=both tubes clear
One natural (monitored) cycle of Clomid, 50mg 2/2012= BFN
Getting ready for first IUI, 3/2012 received orders to Japan! (postponed IUI)
5/2012 Moved to Japan, fought Tricare for months over referral (no fertility treatment on our military base) for Japanese RE out in town!
8/2012 Started seeing new RE
9/2012, post coital test= hostile cervical fluid, (finally) moving on with first IUI!
9/29/2012 IUI #1+trigger= BFN
10/27/2012 IUI #2+100mg Clomid CD5-9+trigger= BFN
11/28/2012 IUI #3+100mg Clomid CD5-9+trigger= BFN
12/28/2012 IUI#4+100mg Clomid CD5-9+trigger=BFN
2/1/2013 IUI#5+injectables+trigger=BFN
3/2013 IUI#6+injectables+trigger=???
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Re: Tricare and Referrals

  • Infertility care is minimally covered (depends on where you are)  but maternity care is fully covered anywhere so not a problem.  GL.
    5/08- blighted ovum, spont ab; 2/20/09- epi, VAVD, Girl! breastfed 24mo; 10/10- blighted ovum, spon ab; 12/10- no fetal pole, Cytotec; 11/20/11- unmedicated SVD, Girl! breastfed 18mo; 11/7/13- unmedicated SVD, breastfed 18mo; 2/11/16- unmedicated SVD, exclusively pumping to at least a year.

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  • I don't think they can deny you prenatal care.  If you went to a RE out in town and payed for everything OOP without anything going through Tricare and then got pregnant I don't know how Tricare would even figure out that you got pregnant through fertility treatment unless they were specifically asking and you said yes.  I would imagine they would just think you got pregnant on your own.

    Your other option could be to switch to Standard which I believe lets you skip the referral process and see a RE out in town that is still in Tricare network.  This will cost you a little more OOP for the deductible but will allow Tricare to still pay for what is is covered such as tests, any surgery you might need such as a lap, or possibly any treatment cycles(per what Tricare will cover).  If you get pregnant Tricare still covers maternity care under standard just like if you were still Prime except for a small daily price while in the hospital giving birth.

    If I have explained any of this wrong someone feel free to correct me, but that is how I understood our options here in the states while doing fertility treatment. 

    Trying To Conceive since November 2009
    Dx: PCOS and MFI
    IUI#1-4 all BFN
    IVF#1 January (4R, 4M, 1F) BFP
    Colt was born on 10/27 at 11:50pm. 6lbs and 19 1/4"
    Surpise! Baby #2 is on it's way.  EDD 9.18.14

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  • Tricare covers diagnostic procedures such as bloodwork, HSG, etc. they cover Clomid as well. They do not cover procedures such as IUI or IVF or the injectibles used during those treatments. If you've already had the fertility work up, get your records. Tricare will to deny prenatal care because realistically, the two really have nothing to do with each other as silly as it sounds. How you get pregnant isn't their concern. You will have to follow their rules when you do get pregnant, which means they tell you where to go.

     If you are ready to move onto IUI or IVF, find a doctor on your own. It's gong to be OOP anyway. If you become pregnant, get a referral for OB care. 

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  • imageLissa832:

     If you are ready to move onto IUI or IVF, find a doctor on your own. It's gong to be OOP anyway. If you become pregnant, get a referral for OB care. 

     

    Thanks, yes this would be our next step. DH has had two normal SA, I have had normal bloodwork, normal HSG, I ovulate on my own and we have tried two monitored cycles of 50mg Clomid. We were in talks with our RE back in San Diego that IUI would be our next step...then we got our orders to Japan and decided to put a hold on everything until we got settled in here.

    TTC our first Navy baby! Me:27 DH:30, together since 8/2003, Married on 7/2006
    9/26/10 stopped BCP and started TTC.
    9/2011 referred to RE. All blood work normal and DH's SA=normal results
    11/2011 HSG=both tubes clear
    One natural (monitored) cycle of Clomid, 50mg 2/2012= BFN
    Getting ready for first IUI, 3/2012 received orders to Japan! (postponed IUI)
    5/2012 Moved to Japan, fought Tricare for months over referral (no fertility treatment on our military base) for Japanese RE out in town!
    8/2012 Started seeing new RE
    9/2012, post coital test= hostile cervical fluid, (finally) moving on with first IUI!
    9/29/2012 IUI #1+trigger= BFN
    10/27/2012 IUI #2+100mg Clomid CD5-9+trigger= BFN
    11/28/2012 IUI #3+100mg Clomid CD5-9+trigger= BFN
    12/28/2012 IUI#4+100mg Clomid CD5-9+trigger=BFN
    2/1/2013 IUI#5+injectables+trigger=BFN
    3/2013 IUI#6+injectables+trigger=???
    image
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