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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), injury, or for the diagnosis and treatment of pregnancy or well-child 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.
Acupuncture Alterations to living spaces Artificial insemination, including in vitro fertilization, gamete intrafallopian transfer, and all other such reproductive technologies Autopsy services or post-mortem examinations Birth control/contraceptives (non-prescription) Bone marrow transplants for treatment of ovarian cancer Camps (e.g., for weight loss) Care or supplies furnished or prescribed by an immediate family member Charges that providers may apply to missed or rescheduled appointments Counseling services that are not medically necessary for the treatment of a diagnosed medical condition (e.g., educational, vocational, and socioeconomic counseling; stress management; or lifestyle modification) Custodial care Diagnostic admissions 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 if 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
Learning disability services Medications:
Drugs prescribed for cosmetic purposes Fluoride preparations Food supplements Homeopathic and herbal preparations Multivitamins Over-the-counter products (except insulin and diabetic supplies) Weight reduction products
Megavitamins and orthomolecular psychiatric therapy Mind expansion and elective psychotherapy Naturopaths Non-surgical treatment of obesity or morbid obesity Personal, comfort, or convenience items, such as beauty and barber services, radio, television, and telephone Postpartum inpatient stay for a mother to stay with a 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 care, such as routine, annual, or employment-requested physical examinations; routine screening procedures; or immunizations, except as provided under the clinical preventive services benefit (See “Clinical Preventive Services” earlier 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 TRICARE-eligible Furnished without charge (i.e., cannot file claims for services provided free-of-charge) For the treatment of obesity, such as diets, weight-loss counseling, weight-loss medications, wiring of the jaw, or similar procedures (See “Services or Procedures with Significant Limitations” earlier in this section.) 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 these 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 (In such instances, TRICARE is the secondary payer for any remaining charges.)
Sex changes or sexual inadequacy treatment, with the exception of treatment of ambiguous genitalia that has been documented to be present at birth Smoking cessation supplies Sterilization reversal surgery Surgery performed primarily for psychological reasons (such as psychogenic surgery) 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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