Provider Handbook - Vision Care

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Vision Care

Routine and comprehensive eye examinations for an evaluation of the eyes not related to another medical or surgical condition may be covered by TRICARE.

TRICARE’s vision coverage varies based on beneficiary category and program option.

Active Duty Service Members

TRICARE Prime ADSMs must receive all vision care at an MTF unless specifically referred to a network provider, or to a non-network provider if a network provider is not available. TPR ADSMs may obtain a comprehensive eye examination from a network provider as needed to maintain fitness-for-duty status without an authorization.

Active Duty Family Members

ADFMs are covered for one eye examination annually, regardless of their program option (TRICARE Prime, TRICARE Standard, etc.).

Retired Service Members, Family Members, and Others

Retired service members, their families, and others who are enrolled in TRICARE Prime are covered for eye examinations under TRICARE Prime’s clinical preventive services benefit. See Figure 5.1 for coverage details.

Figure 5.1 TRICARE Prime Vision Care Coverage for Retirees and Their Families

Beneficiary	Coverage	Provider
Infants	One eye and vision screening at birth and 6 months	Assigned PCM
Children (ages 3 - 6)	One routine eye exam every two years	Optometrist or ophthalmologist
Adults and Children over Age 6	One routine eye exam every two years	Optometrist or ophthalmologist

For retired service members, their families, and others using TRICARE Standard or TRICARE Extra, there is no vision coverage provided after age 6. Vision care for infants and children up to age 6 is covered under the well-child benefit.

Well-Child Vision Benefit for Infants and Children up to Age 6

Vision care coverage is provided under the TRICARE well-child benefit for all TRICARE eligible infants and children up to age 6, regardless of program option. See Figure 5.2 for coverage details.

Figure 5.2 TRICARE Well-Child Vision Care Coverage

Beneficiary	Coverage	Provider
Infants	One eye and vision screening at birth and 6 months	Primary care physician (e.g., pediatrician, family practitioner)
Children (ages 3 - 6)¹	One routine eye exam every two years	Optometrist or ophthalmologist

¹ ADFM children are covered for one routine eye exam annually.

Eyeglasses, Contact Lenses, and Implantable Lenses

ADSMs are covered for eyeglasses at MTFs at no cost. To obtain eyeglasses or contact lenses outside of the MTF, ADSMs should contact the Naval Ophthalmic Support and Training Activity or by phone at 1-757-887-7611.

For all other TRICARE beneficiaries, contact lenses or eyeglasses are only cost-shared with prior authorization for treatment of infantile glaucoma, keratoconus, dry eyes when normal tearing is inadequate or absent, corneal irregularities other than astigmatism, or loss of human lens function resulting from eye surgery or congenital absence.

Benefits are limited to only one set of implantable lenses required to restore vision. A set may include a combination of both implantable lenses and eyeglasses when the combination is necessary to restore vision. If there is a prescription change related to the qualifying eye condition, a new set may be cost-shared.

Replacement lenses for those that are lost, have deteriorated, or have become unusable due to physical growth are not covered. Adjustments, cleaning, and repairs of eyeglasses are also not covered.

Other

Medically necessary eye exams are covered for all categories of TRICARE beneficiaries. TRICARE Prime beneficiaries need prior authorization for medically necessary visits if they are not performed at an MTF.

Diabetic beneficiaries enrolled in TRICARE Prime are covered for an eye exam each year, regardless of their sponsor’s military status. There is no copayment for these exams.

For more information about TRICARE’s vision coverage, access Chapter 7, Sections 2.1–2.2 of the TRICARE Policy Manual.

Last Update: August 26, 2009