| Service |
Description |
| Abortions |
Abortions are only covered when the life of the mother would be endangered if the pregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a life-threatening condition existed. Medical documentation must be provided. MTFs may not be able to provide such services based upon limited capabilities. |
| 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 for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded. |
| Chiropractic Care |
Coverage is limited to ADSMs and is only available at specific MTFs under the Chiropractic Care Program. This program is not available under TRS. |
| Cosmetic, Plastic, or Reconstructive Surgery |
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, or after a medically necessary mastectomy. |
| Cranial Orthotic Device or Molding Helmet |
Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. |
| 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 ). |
| Education and Training |
Outpatient diabetic self-management and training programs are covered when the services are provided by a TRICARE-authorized individual provider who also meets national standards for diabetes self-management education programs recognized by the American Diabetes Association® (ADA). The provider’s “Certificate of Recognition” from the ADA must accompany the claim for reimbursement. |
Eyeglasses or
Contact Lenses |
Contact lenses and/or eyeglasses are covered only 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.
|
| Food, Food Substitutes or Supplements, or Vitamins |
Covered when used as the primary source of nutrition for enteral, parenteral, or oral nutritional therapy. Intraperitoneal nutrition (IPN) therapy is covered for malnutrition as a result of end-stage renal disease. |
| Gastric Bypass |
Gastric bypass, gastric stapling, or gastroplasty—to include vertical banded gastroplasty—is covered when one of the following conditions is met:
- The patient is 100 pounds over the ideal weight for height and bone structure and has one of these associated medical conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratory diseases), hypothalamic disorders, or severe arthritis of the weight-bearing joints.
- The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
- The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown ).
|
| General Anesthesia Services and Institutional Costs for Non-Adjunctive Dental Treatment |
Covered when medically necessary to safeguard a patient’s life or in conjunction with non-adjunctive dental treatment (dental care not related to a medical condition) for patients with developmental, mental, or physical disabilities and for patients age 5 or under. |
| Genetic Testing |
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. |
| Laser/LASIK/Refractive Corneal Surgery |
Covered only to relieve astigmatism following a corneal transplant. |
| Private Hospital Rooms |
Not covered unless ordered for medical reasons or 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 only receive 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 when a permanent part of a brace. For individuals with diabetes, extra-depth shoes with inserts or custom-molded shoes with inserts may be covered. |
