Before you refer a TRICARE beneficiary to a specialist, it’s best to verify whether the service or procedure is a TRICARE-covered benefit. TRICARE covers most medically necessary, proven inpatient and outpatient care. However, some medical/surgical services are excluded from coverage while others are subject to significant limitations.
 
Medically or psychologically necessary services and supplies include those used for the diagnosis or treatment of a covered illness (including behavioral health disorders), injury, pregnancy or well-child care. Note: Active duty service members (ADSMs) must always have a referral from their primary care manager for behavioral health care.
 
The following services and procedures are excluded by TRICARE under any circumstance:

• Acupuncture
• Artificial insemination
• Birth control (non-prescription)
• Experimental or unproven procedures
• Foot care (routine)
• Hair transplants
• Laser/LASIK/refractive corneal surgery
• Non-surgical treatment of obesity or morbid obesity

Note: Military treatment facilities have the authority to authorize non-covered services on a case-bycase
basis only for ADSMs.
 
Some services that are covered but with significant limitations include:

• Chiropractic care
• Cosmetic, reconstructive and plastic surgery
• Hearing aids
• Obesity surgery/treatment

Note: These lists are not intended to be all-inclusive.
 
Cosmetic, reconstructive and/or plastic surgery may be covered if related to correcting a congenital anomaly, restoring body form following an accidental injury, revising disfi guring/extensive surgical scars or reconstructing the breast (e.g., following medically necessary mastectomy).
 
Hearing aids and related supplies and services may be covered for adult active duty family members with profound hearing loss or a speech recognition score of less than 94 percent when tested. Additionally, dependent children of ADSMs with hearing loss may be covered if they have a 26 dB HL or greater hearing threshold in one or both ears when tested in the frequency range of 500, 1,000, 2,000, 3,000 or 4,000 Hz. More information on hearing aid coverage can be found in the TRICARE Policy Manual, Chapter 7, Section 8.2.
 
While non-surgical obesity treatments are not covered, surgical weight loss procedures (i.e., gastric bypass, gastric stapling, vertical banded gastroplasty and laparoscopic adjustable banding) are covered under certain circumstances. Patients who are 100 pounds or more over their ideal weight and have certain associated serious medical conditions (e.g., diabetes, hypertension or severe arthritis of the weight-bearing joints) and patients at 200 percent or more of their ideal body weight may qualify for weight loss surgery.
 
Understanding TRICARE coverage guidelines before services are rendered is the key to obtaining appropriate reimbursement.For a complete list of procedures excluded by TRICARE, refer to the No Government Pay Procedure Code List on the TRICARE Web site.

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