Services or Procedures with Significant Limitations

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.

Below is a list of medical, surgical, and behavioral health care services that may not be covered unless exceptional circumstances exist. Note: This figure is not all-inclusive.

Services or Procedures with Significant Limitations

 Service Description
Bariatric Surgery  These procedures are covered for the treatment of morbid obesity under certain limited circumstances. For more information, contact Humana Military or visit TRICARE's website.
Botulinum Toxin Type A Injections Botulinum toxin injections for cosmetic procedures, myofascial pain, and fibromyalgia are not covered. Cost-sharing may apply for injections to treat certain other defined conditions.
Breast Pumps Heavy-duty, hospital-grade electric breast pumps (including services and supplies related to the use of the pump) for mothers of premature infants are covered. An electric breast pump is covered while the premature infant remains hospitalized during the immediate postpartum period. Hospital-grade electric breast pumps may also be covered after the premature infant is discharged from the hospital with a physician-documented medical reason. This documentation is also required for premature infants delivered in non-hospital settings. Breast pumps of any type, when used for reasons of personal convenience, are excluded even if prescribed by a physician.
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 Surgery is 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 after neoplastic surgery, or reconstruct the breast after cancer surgery.
Cranial Orthotic Device or Molding Helmet Cranial orthotic devices are covered for adjunctive use for infants from 3–18 months of age whose synostosis has been surgically corrected, but who still have moderate to severe cranial deformities. Cranial orthotic devices are excluded for treatment of nonsynostotic positional plagiocephaly or for the treatment of craniosynostosis before surgery.
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).  Prior authorization is required for adjunctive dental care.
Education and Training Education and training are only covered under the TRICARE Extended Care Health Option (ECHO) and diabetic outpatient self-management training programs. Diabetic outpatient self-management training programs must be accredited by the American Diabetes Association®. The provider’s accreditation certificate must accompany the claim for reimbursement.
Eyeglasses or
Contact Lenses
Active duty service members (ADSMs) may receive eyeglasses at military treatment facilities at no cost. For all other beneficiaries, the following are covered:
  • Contact lenses and/or eyeglasses 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.
Facility Charges for Non-Adjunctive Dental Services Hospital and anesthesia charges related to routine dental care for children under age 5, or those with disabilities, may be covered in addition to dental care related to some medical conditions.
Food, Food Substitutes and Supplements, or Vitamins Medically necessary nutrition formulas are covered 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. Vitamins may be cost-shared only when used as a specific treatment of a medical condition. Additionally, prenatal vitamins that require a prescription may be cost-shared, but are covered for prenatal care only.
Genetic Testing Testing is covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient. Routine genetic testing is not covered.
Hearing Aids Hearing aids are covered only for active duty family members who meet specific hearing-loss requirements.
  • Hearing aids are excluded under any circumstance for retirees, retiree family members, TRICARE Reserve Select (TRS) members, and TRICARE Retired Reserve (TRR) members.
  • TRICARE Young Adult coverage for hearing aids is derived from the young adult’s sponsor status. If the sponsor is an active duty service member, hearing aids are covered the same as for an ADFM. If the sponsor is a retiree, TRS member, or TRR member, hearing aids are excluded under any circumstance.
Laser/LASIK/Refractive Corneal Surgery Surgery is covered only to relieve astigmatism following a corneal transplant.
Private Hospital Rooms Private rooms are not covered unless ordered for medical reasons or because 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 receive only the standard DRG amount. The hospital may bill the patient for the extra charges if the patient requests a private room.
Shoes, Shoe Inserts, Shoe Modifications, and Arch Supports Shoe and shoe inserts are covered only in very limited circumstances. Orthopedic shoes may be covered if they are a permanent part of a brace. For beneficiaries with diabetes, extra-depth shoes with inserts or custom-molded shoes with inserts may be covered.

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Last Update: October 19, 2013