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TRICARE covers most inpatient and outpatient care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. The beneficiary liability for covered services is determined by the program option the beneficiary is using (TRICARE Prime, TRICARE Prime Remote [TPR], TRICARE Prime Remote for Active Duty Family Members [TPRADFM], TRICARE Standard, TRICARE Extra, or TRICARE For Life [TFL]). See the TRICARE Program Options section for specific beneficiary liability information.
In this section, the TRICARE-covered services are highlighted and specific details about some of the more complex benefits are included. This section is not intended to be all inclusive.
For additional information or specific questions about TRICARE-covered services, contact Humana Military Healthcare Services, Inc., (Humana Military) at 1-800-444-5445, or review the TRICARE Policy Manual, TRICARE Reimbursement Manual, and TRICARE Operations Manual online. You can also review the TRICARE Provider News publication for regular articles about benefits and program changes.
Some military treatment facilities (MTFs) may offer services or procedures that are not covered by TRICARE. Beneficiaries should contact their local MTF for more information about these services. Additionally, the Military Medical Support Office (MMSO) may authorize services for active duty service members (ADSMs) that are not regular TRICARE benefits. As long as the advance authorization is in place, providers will be paid accordingly.
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TRICARE covers individual provider services such as routine office visits; outpatient office-based medical and ambulatory (same-day) surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation (except for chiropractic care); rehabilitation services, e.g., physical therapy, speech pathology services, and occupational therapy; and medical supplies used within the office, including casts, dressings, and splints. Also included are certain diagnostic radiology and ultrasound (70000-76999); diagnostic nuclear medicine (78000-78999); pathology and laboratory services (80000-89399); and cardiovascular studies (93000-93350). Note: Additional TRICARE Prime copayments are not applied if these services are provided as part of an office visit.
TRICARE covers inpatient services, as long as they are medically necessary. Hospitalization is covered in a semi-private room (or in special care units when medically necessary) and includes general nursing, hospital service, inpatient physician, and surgical services; meals, including special diets; drugs and medications while an inpatient; operating and recovery room; anesthesia; laboratory tests; X-rays and other radiology services; necessary medical supplies and appliances; and blood and blood products.
The following services will be discussed in more detail:
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