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Clinical Preventive Services
    


Figure 3.3 provides coverage details for covered clinical preventive services. Note: This chart is not intended to be all-inclusive.

Figure 3.3 Clinical Preventive Services: Coverage Details
 

Service Description
Comprehensive Health Promotion and Disease Prevention Examinations 
A comprehensive clinical preventive exam is covered if it includes an immunization, Pap smear, mammogram, colon cancer screening, or prostate cancer screening. School enrollment physicals for children ages 5–11 are also covered.
Targeted Health Promotion and Disease Prevention Services  The screening examinations listed below may be covered if provided in conjunction with a comprehensive clinical preventive exam. The intent is to maximize preventive care.
Cancer Screenings
  • Colonoscopy: Perform a colonoscopy once every 10 years starting at age 50, or as listed below for individuals at increased risk for:
    • Hereditary non-polyposis colorectal cancer syndrome: Perform a colonoscopy once every two years beginning at age 25, or five years younger than earliest age of diagnosis in affected relative(s), whichever is earlier, and then annually after age 40.
    • Familial risk of sporadic colorectal cancer: For first-degree relatives with sporadic colorectal cancer or adenoma before age 60, or with multiple first-degree relatives with colorectal cancer or adenomas, perform a colonoscopy every three to five years, beginning 10 years earlier than the youngest affected relative.
  • Fecal occult blood testing: Conduct testing annually starting at age 50.
  • Mammograms: Perform a mammography annually for those over age 39. For high-risk patients, a baseline mammogram is appropriate at age 35 and annually thereafter.
    • Magnetic resonance imaging (MRI): Perform an MRI annually for asymptomatic beneficiaries age 35 or older considered to be at high risk for developing breast cancer by American Cancer Society® guidelines. The guidelines include women with a:
      • BRCA1 or BRCA2 gene mutation
      • First-degree relative (parent, child, or sibling) with a BRCA1 or BRCA2 gene mutation
      • Lifetime risk of approximately 20–25 percent or greater as defined by BRCAPRO or other models that are largely dependent on family history
      • History of chest radiation between ages 10–30
      • History of Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with one of these syndromes
  • Physical exam for colorectal cancer: A digital rectal exam should be included in periodic health exams of individuals age 40 and older.
  • Proctosigmoidoscopy or sigmoidoscopy: Conduct the procedure once every three to five years beginning at age 50.
  • Prostate cancer: Perform a digital rectal exam and prostate-specific antigen screening annually for certain high-risk men ages 40–49 and all men over age 50.
  • Routine Pap smears: Perform a Pap smear annually for women starting at age 18 (younger if sexually active) or less often at patient and provider discretion (though not less than every three years). Routine human papillomavirus (HPV) screenings are not covered.
  • Skin cancer: Exams are covered at any age for a beneficiary who is at high risk due to family history or increased sun exposure.
Cardiovascular Diseases
  • Cholesterol test: Testing is covered for a lipid panel at least once every five years, beginning at age 18.
  • Blood pressure screening: Screening is covered annually for children (ages 3–6) and a minimum of every two years after age 6 (children and adults).
Eye Examinations
  • Well-child care coverage (infants and children up to age 6):
  • Infants: One eye and vision screening is covered at birth and at 6 months.
  • Children (ages 3–6): One routine eye exam is covered every two years. Active duty family member (ADFM) children are covered for one routine eye exam annually.
  • Adults and children (over age 6): Active duty service members and ADFMs receive one eye exam each year.
  • Diabetic patients (any age): Eye exams are not limited. One eye exam per year is recommended.
  • Retired service members, their families, and others: Not covered after age 6.
Hearing Preventive hearing examinations are only allowed under the well-child care benefit. A newborn audiology screening should be performed on high-risk newborns before hospital discharge or within the first three months after birth. Evaluative hearing tests may be performed at other ages during routine exams.
Immunizations Age-appropriate vaccines, including annual influenza vaccines, are covered as recommended by the Centers for Disease Control and Prevention (CDC). The HPV vaccine is covered for all females ages 11–26 who have not completed the vaccine series, regardless of sexual activity or clinical evidence of previous HPV infection. The HPV vaccine is not covered after age 26. The TRICARE medical (not pharmacy) benefit covers a single dose of the shingles vaccine Zostavax,® administered in a provider’s office, for beneficiaries age 60 and older.

Coverage is effective the date the recommendations are published in the CDC’s Morbidity and Mortality Weekly Report. Refer to the CDC's web site for a current schedule of recommended vaccines.

Note: Immunizations for ADFMs whose sponsors have permanent change of station orders to overseas locations are also covered.
Infectious Disease Screening TRICARE covers screening for infectious diseases, including hepatitis B, rubella antibodies and HIV, and screening and/or prophylaxis for tetanus, rabies, Rh immune globulin, hepatitis A and B, meningococcal meningitis, and tuberculosis. Routine HPV screening is not covered.
Patient and Parent Education Counseling Counseling services expected of good clinical practice that are included with the appropriate office visit are covered at no additional charge for dietary assessment and nutrition; physical activity and exercise; cancer surveillance; safe sexual practices; tobacco, alcohol, and substance abuse; dental health promotion; accident and injury prevention; stress; bereavement; and suicide risk assessment.
School Physicals  Covered for children ages 5–11 if required in connection with school enrollment.

Note: Annual sports physicals are not covered.
Well-child Services  Covers routine newborn care; comprehensive health promotion and disease prevention exams; vision and hearing screenings; height, weight, and head circumference measurement; routine immunizations; and developmental and behavioral appraisal. TRICARE covers well-child care in accordance with American Academy of Pediatrics (AAP) and CDC guidelines. Your child can receive preventive care well-child visits as frequently as the AAP recommends, but no more than nine visits in two years. Visits for diagnosis or treatment of an illness or injury are covered separately under outpatient care.

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Last Reviewed: June 9, 2010