MOAA’s TRICARE Toolkit provides insight and tips for navigating your TRICARE benefits. Have a question or suggestion for an upcoming column? Email [email protected]. Read other TRICARE Toolkit columns at MOAA.org/tricaretoolkit.
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Obesity continues to be a critical health issue that affects millions of Americans. Around 40% of adults are obese, and severe obesity prevalence increased from 4.7% to 9.2% from 2000 to 2020, according to the Centers for Disease Control and Prevention. The estimated annual medical cost of obesity in the U.S. reached $173 billion in 2019.
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Obesity is frequently subdivided into three categories by adult Body Mass Index (BMI):
- Class 1: BMI of 30 to < 35
- Class 2: BMI of 35 to < 40
- Class 3: BMI of 40 or higher (“severe” or “morbid”)
TRICARE.mil states it only covers morbid obesity surgery such as gastric bypass, gastric stapling, sleeve gastrectomy, standalone laparoscopic sleeve gastrectomy, and gastroplasty when the beneficiary meets one of the following conditions:
- Is 100 pounds over ideal weight for height and bone structure and has been diagnosed with one of these conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders, or severe arthritis of the weight-bearing joints.
- Is 200% or more over ideal weight for height and bone structure.
- Has had intestinal bypass or other surgery for obesity and, because of complications, requires another surgery.
However, a TRICARE Communications article published in January states that under specific conditions TRICARE will cover intensive, multicomponent behavioral interventions for obesity. A TRICARE-authorized provider, such as a physician or a registered dietician (under the supervision of a physician) must be used for TRICARE to cover them.
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To qualify for nonsurgical services, you must be:
- An adult with a BMI of 30 or higher.
- A child with a BMI greater than the 95th percentile.
Pharmacy Help
TRICARE has added FDA-approved weight-loss drugs to the pharmacy formulary to curb appetites, boost metabolism, or block absorption of starches and fats. To be considered for a weight-loss medication prescription, patients must have a BMI higher than 29 or 26 if they have a related weight-based condition.
Obtaining access to weight loss prescriptions requires prior authorization and participation in a behavior modification program (diet and exercise) for six months before receiving the medication.
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