IORT & Insurance

pokemom - I also have Tricare Prime and have been involved with two clinical trials, but did not have IORT, or conventional rads. It is also offered here in Tampa at Moffitt Cancer Center. Both of the trials I have participated in have not involved my insurance - generally clinical trials are gathering information on unproven modalities so the trial costs are borne by whoever is conducting the trial. Are they telling you that Tricare needs to pay for the IORT rads? The only danger I see with Tricare is that they sometimes will not pay for anything termed "experimental" - even if FDA approved. Tricare denied payment for Mammaprint testing for me for this reason, so if they are solicited for payment for IORT they may deny simply because it is in a trial setting.

pokemom - the info from Tricare sounds promising, but I couldn't get the second link to work - it is giving me an error. When I searched NCI with IORT I did not get the institution you referred to in your original post. The easiest thing to do it talk to both St. Joseph's and ask if they are billing insurance for IORT or is that already covered by trial monies, then talk to Tricare and ask specifically if they approve IORT. All moving parts of your treatment require advance referral with Tricare Prime so you will know beforehand if they will pay for it, and it should be part of your surgical referral since it is part of the lumpectomy surgery. I would also ask your BS to seek the referral auth ASAP so you can get these questions answered well in advance.

Pokemom, I had IORT in Feb. My RO said it cost about 1/3 of conventional radiation and he had never had a problem getting it approved with my insurance, United Healthcare. They paid with no problem except for the portion that was applied to my deductible.

pokemom - when you find out the insurance answer please come back and post.  The information will be helpful to others with the same questions.  I hope this works out for you!

pokemom - hopefully you can make this work!  I had a skin/nipple sparing BMX and my BS, to whom I was referred through Tricare, requested an out-of-network PS because that is who he uses for that particular surgery.  Tricare approved the out-of-network PS, even though there were available in-network PS, because of the BS request.  I have had 7 out of my 8 surgeries with this PS, long after the interaction with the BS, and Tricare has paid for every one of them with no questions asked.  Good luck!

I have been very happy with Tricare - they refused one item, the Mammaprint test, which although FDA approved, it considered experimental by Tricare.  It is a $5,000 test so that bill was a shock when it came in the mail.  The BS office had failed to obtain an auth in advance of sending the test though (they would have known that Tricare would not pay if they did!) and I did not sign anything saying I would be responsible for any unpaid balance.  Tricare paid the shipping cost for the test to go to Agendia Labs in California, so I requested an AOB (Assignment of Benefits) form which states they will accept what insurance pays - so they got $61, and that was it!