| Service |
Description |
| Abortions |
Abortions are covered only when the life of the mother would be endangered if the pregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a life-threatening condition existed. Medical documentation must be provided. |
| Cardiac and Pulmonary Rehabilitation |
Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded. |
| Cosmetic, Plastic, or Reconstructive Surgery |
Only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement, or after a medically necessary mastectomy. |
| Cranial Orthotic Device or Molding Helmet |
Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. |
| Facility Charges for non-adjunctive Dental Services |
Covered only to safeguard a patient’s life. |
| Dental Care and Dental X-rays |
Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition). |
| Education and Training |
Outpatient diabetic self-management and training programs are covered when the services are provided by a TRICARE-authorized individual provider who also meets national standards for diabetes self-management education programs recognized by the American Diabetes Association (ADA). The provider’s “Certificate of Recognition” from the ADA must accompany the claim for reimbursement. |
| Eyeglasses or Contact Lenses |
Active duty service members may receive eyeglasses at MTFs at no cost. For all other beneficiaries, contact lenses and/or eyeglasses are only covered for treatment of:
- Infantile glaucoma
- Corneal or scleral lenses for treatment of keratoconus
- Scleral lenses to retain moisture when normal tearing is not present or is inadequate
- Corneal or scleral lenses to reduce corneal irregularities other than astigmatism
- Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from intraocular surgery, ocular injury, or congenital absence
Note: Adjustments, cleaning, and repairs for eyeglasses are not covered
|
| Food, Food Substitutes or Supplements, or Vitamins |
When used as the primary source of nutrition for enteral, parenteral, or oral nutritional therapy. Intraperitoneal nutrition therapy is covered for malnutrition as a result of end-stage renal disease. |
| Gastric Bypass |
Gastric bypass, gastric stapling, or gastroplasty—to include vertical banded gastroplasty—is covered when one of the following conditions is met:
- The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders, and severe arthritis of the weight-bearing joints.
- The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
- The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).
|
| Genetic Testing |
Covered only under certain conditions. |
| Hearing Aids |
Covered only for active duty family members who meet specific hearing loss requirements. |
| Intelligence Testing |
Covered only when medically necessary for the diagnosis or treatment planning of covered psychiatric disorders. |
| Laser/LASIK/Refractive corneal surgery |
Covered only to relieve astigmatism following a corneal transplant. |
| Marital Therapy and/or Couples Counseling |
Covered only for beneficiaries with behavioral health disorder as a primary diagnosis, and the marital or couples therapy must be medically necessary. |
| Private Hospital Rooms |
Not covered unless ordered for medical reasons or a semiprivate room is not available. Hospitals that are subject to the TRICARE diagnosis-related group (DRG) payment system may provide the patient with a private room but will only receive the standard DRG amount. The hospital may bill the patient for the extra charges if the patient requests a private room. |
| Weight Reduction |
Services and supplies related to obesity or weight reduction, whether surgical or non-surgical, are excluded except for gastric bypass, gastric stapling, or gastroplasty procedures in connection with morbid obesity. |
