The following listed services are covered with significant limitations:
  

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.

Botulinum toxin type A injections: Botulinum toxin type A injections for cosmetic procedures, myofacial pain, fibromyalgia, and headaches are not covered. Cost-sharing may apply for injections to treat severe primary auxiliary hyperhydrosis, dystonia-related blepharospasm or strabismus, cervical dystonia, or cerebral palsy-related spasticity. TRICARE may also consider off-label cost-sharing for Botox® injections used to treat chronic anal fissure (if unresponsive to conservative therapeutic measures).

Breast pumps: Heavy-duty, hospital-grade (E0604) 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 for 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. Manual breast pumps (E0602) and basic (non-hospital grade) electric pumps (E0603) are also excluded.

Cardiac and pulmonary rehabilitation: Cardiac and pulmonary rehabilitation are covered only 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. For more information, visit the TRICARE web site.

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 cancer surgery, or for breast reconstruction after cancer surgery.

Cranial orthotic device or molding helmet: Cranial orthotic devices are covered only for postoperative use for infants (3–18 months) who have undergone surgical correction of craniosynostosis and have moderate-to-severe residual cranial deformities. TRICARE does not cover devices and helmets for treatment of nonsynostotic positional plagiocephaly or for the treatment of craniosynostosis before surgery.

Dental care and dental X-rays: Only non-adjunctive (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition) dental care and X-rays are covered.

Diagnostic genetic testing: TRICARE only covers medically proven and appropriate diagnostic genetic testing if the results will influence a patient’s medical management. Services should be billed using the appropriate Evaluation and Management codes. Refer to the TRICARE Policy Manual, Chapter 6, Section 3.1 at TRICARE Manuals Online. For antepartum services, refer to the TRICARE Policy Manual, Chapter 4, Section 18.2.

Education and training: Education and training are only covered under the TRICARE ECHO and diabetic outpatient self-management training services. Diabetic outpatient self-management training services must be performed by programs approved by the American Diabetes Association.® The provider’s “Certificate of Recognition” from the American Diabetes Association must accompany the claim for reimbursement.

Eyeglasses and contact lenses: ADSMs may receive eyeglasses at MTFs at no cost. For all other beneficiaries, the following are covered, with prior authorization from Humana Military:

TRICARE beneficiaries in the South Region require prior authorization from Humana Military for bariatric surgery. Providers should consider referring bariatric surgery candidates to Bariatric Surgery Centers of Excellence.

Genetic testing: Testing is only covered when medically proven and appropriate, and when the results of the test will influence the medical management of the patient.

Hearing aids: Hearing aids and certain repairs are covered only for ADFMs who meet specific hearing-loss requirements.

Intelligence testing: Testing is covered only when medically necessary for the diagnosis or treatment planning of covered psychiatric disorders.

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: Shoes and shoe inserts are covered only in limited circumstances. Orthopedic shoes may be covered if they are a permanent part of a brace. For individuals with diabetes, extra-depth shoes with inserts or custom-molded shoes with inserts may be covered. For more information, refer to the TRICARE Policy Manual, Chapter 8, Section 3.1 at TRICARE Manuals Online. 

Vitamins: Cost-sharing may apply for legend vitamins specifically used to treat medical conditions. Additionally, prescription prenatal vitamins for prenatal care may be cost-shared.