Prime Remote Handbook

In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder) or injury or for the diagnosis and treatment of pregnancy or well-baby care. All services and supplies (including inpatient institutional costs) related to a non-covered condition or treatment, or provided by an unauthorized provider, are excluded.

The following specific services are excluded under any circumstance. This list is not intended to be all-inclusive. Check Humana Military’s Web site for additional information.
       

• Acupuncture
• Air conditioners, humidifiers, dehumidifiers, and purifiers
• Artificial insemination, including in-vitro fertilization, gamete intrafallopian transfer, and all other such reproductive technologies
• Autopsy services or postmortem examinations
• Bariatric surgery, except as outlined under Gastric Bypass and Weight Reduction in Figure 4.6, “Services or Procedures with Significant Limitations”
• Birth control/contraceptives (non-prescription)
• Camps (e.g., weight loss)
• Charges that providers may apply due to a missed or rescheduled appointment
• Chiropractic care (Visit the Chiropractic Health Care Program for active duty service members for details.)
• Clothing or shoes, even if required by virtue of an allergy
• Counseling services that are not medically necessary in the treatment of a diagnosed medical condition. For example, educational counseling, vocational counseling, and counseling for socioeconomic purposes, stress management, life-style modification, etc.
• Custodial care
• Diagnostic admissions
• Diagnostic tests to establish paternity of a child or tests to determine the sex of a fetus
• Domiciliary care
• Dyslexia treatment
• Electrolysis
• Elevators or chair lifts
• Exercise equipment, spas, whirlpools, hot tubs, swimming pools, health club memberships, or other such charges or items
• Experimental or unproven procedures
• Foot care (routine), except those required as a result of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes
• General exercise programs, even if recommended by a physician and regardless of whether rendered by an authorized provider
• Inpatient stays:
  • For rest or rest cures
  • To control or detain a runaway child, whether or not admission is to an authorized institution
  • To perform diagnostic tests, examinations, and procedures that could have been and are performed routinely on an outpatient basis
  • In hospitals or other authorized institutions above the appropriate level required to provide necessary medical care
• Laparoscopic adjustable gastric banding (Lap-Band procedure)
• Learning disability services
• Megavitamins and orthomolecular psychiatric therapy
• Mind expansion and elective psychotherapy
• Naturopaths
• Orthopedic shoes (except if an integral part of a brace), arch supports, shoe inserts, and other supportive devices for the feet, including special-ordered, custom-made built-up shoes, or regular shoes later built up
• Personal, comfort, or convenience items, such as beauty and barber services, radio, television, and telephone
• Postpartum inpatient stay of a mother for purposes of staying with the newborn infant (usually primarily for the purpose of breastfeeding the infant) when the infant (but not the mother) requires the extended stay; or continued inpatient stay of a newborn infant primarily for purposes of remaining with the mother when the mother (but not the newborn infant) requires extended postpartum inpatient stay
• Preventive routine annual or employment-requested examinations; routine screening procedures; immunizations; except such preventive care, immunizations, and cancer screenings provided in the Clinical Preventive Services list (see “Clinical Preventive Services” in this section).
• Psychiatric treatment for sexual dysfunction
• Services and supplies
  • Provided under a scientific or medical study, grant, or research program
  • Furnished or prescribed by an immediate family member
  • For which the beneficiary has no legal obligation to pay or for which no charge would be made if the beneficiary or sponsor were not eligible under TRICARE
  • Furnished without charge (e.g., cannot file claims for services provided free-of-charge)
  • For the treatment of obesity, except as outlined in “Services or Procedures with Significant Limitations.” Diets, weight loss counseling, weight loss medications, wiring of the jaw, or any similar procedure is excluded.
  • Inpatient stays, directed or agreed to by a court or other governmental agency (unless medically necessary)
  • Required as a result of occupational disease or injury for which any benefits are payable under a worker’s compensation or similar law, whether such benefits have been applied for or paid, except if benefits provided under such laws are exhausted.
  • That are (or are eligible to be) fully payable under another medical insurance or program, either private or governmental, such as coverage through employment or Medicare (TRICARE will be secondary for any remaining charges.)
• Sex changes or sexual inadequacy treatment (However, treatment of ambiguous genitalia which has been documented to be present at birth is covered.)
• Sterilization reversal surgery
• “Stop smoking” regimens (except for active duty service members with MMSO approval)
• Surgery performed primarily for psychological reasons (such as psychogenic
• Therapeutic absences from an inpatient facility, except when such absences are specifically included in a treatment plan approved by TRICARE
• Transportation, except by ambulance
• X-ray, laboratory, and pathological services and machine diagnostic tests not related to a specific illness or injury or a definitive set of symptoms, except for cancer screening mammography, cancer screening, Pap tests, and other tests allowed under the Clinical Preventive Services benefit

    
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