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HEALTH
PROMOTION AND DISEASE PREVENTION (HP&DP) EXAMINATIONS
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For ages six
year and or older: One HP&DP examination is covered annually.
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WELL WOMAN EXAMINATIONS
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HP&DP exams
for the purpose of a well woman exam are covered annually for female beneficiaries
under age 65. If the primary care clinician determines that a patient
requires additional well woman visits to obtain all necessary recommended
preventive services that are age and developmentally appropriate,
these may be provided without copay and subject to reasonable medical
management.
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TARGETED
CLINICAL PREVENTIVE SERVICES
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The following
clinical preventive services may be performed during either an HP&DP exam
or a well woman exam.
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Breast
Cancer:
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Clinical
Breast Examination (CBE): A CBE may be performed during a
covered HP&DP exam.
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BRCA1
or BRCA2 Genetic Counseling and Testing: Genetic counseling
rendered by a TRICARE-authorized provider that precedes BRCA1 or
BRCA2 gene testing is covered for women who are identified as high
risk for breast cancer by their primary care clinician.
BRCA1
or BRCA2 gene testing is covered for women who meet the coverage
guidelines outlined in the TRICARE Operations Manual (TOM), Chapter 18, Section 3, Figure 18.3-1. |
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Screening
Mammography: Covered annually for all women beginning at
age 40. Covered annually beginning at age 30 for women who have
a 15% or greater lifetime risk of breast cancer (according to risk
assessment tools based on family history such as the Gail model,
the Claus model, and the Tyrer-Cuzick model), or who have any of
the following risk factors:
1.
History of breast cancer, Ductal Carcinoma In Situ (DCIS), Lobular
Carcinoma In Situ (LCIS), Atypical Ductal Hyperplasia (ADH), or
Atypical Lobular Hyperplasia (ALH);
2.
Extremely dense breasts when viewed by mammogram;
3.
*Known BRCA1 or BRCA2 gene mutation;
4.
*First-degree relative (parent, child, sibling) with a BRCA1 or
BRCA2 gene mutation, and have not had genetic testing themselves;
5.
Radiation therapy to the chest between the ages of 10 and 30 years;
or
6. History of Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba
syndrome, or a first-degree relative with a history of one of these
syndromes.
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Note: The
risk factors identified above for screening mammography are those
established by the American Cancer Society.
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Breast
Screening Magnetic Resonance Imaging (MRI): Covered annually,
in addition to the annual screening mammogram, beginning at age
30 for women who have a 20% or greater lifetime risk of breast cancer
(according to risk assessment tools based on family history such
as the Gail model, the Claus model, and the Tyrer-Cuzick model),
or who have any of the following risk factors:
1.
*Known BRCA1 or BRCA2 gene mutation;
2.
First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2
gene mutation, and have not had genetic testing themselves;
3.
Radiation to the chest between the ages of 10 and 30; or
4.
History of LiFraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome,
or a first-degree relative with a history of one of these syndromes.
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Note:
The risk factors identified above for breast cancer screening MRI
are those established by the American Cancer Society.
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Cervical
Cancer
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Pelvic
Examination: A pelvic examination should be performed as
part of a well woman exam and in conjunction with Pap smear testing
for cervical neoplasms and premalignant lesions.
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Pap
Smears: For dates of service prior to May 8, 2015, cancer
screening Pap smears should be performed for women who are at risk
for sexually transmittable diseases, women who have or have had
multiple sexual partners (or if their partner has or has had multiple sexual
partners), women who smoke cigarettes, and women 18 years of age
and older when provided under the terms and conditions contained
in the guidelines adopted by the Director, Defense Health Agency
(DHA). The frequency of the screening Pap smears will be at the
discretion of the patient and clinician but not less frequent then
every three years.
For dates of
service on or after May 8, 2015, cancer screening Pap smears are
covered for female beneficiaries beginning at age 21. Women under
age 21 should not be screened regardless of the age of sexual initiation
or other risk factors. The frequency of screening Pap smears may
be at the discretion of the patient and clinician; however, screening
Pap smears should not be performed less frequently than once every
three years.
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Human
Papillomavirus (HPV) Deoxyribonucleic Acid (DNA) Testing:
HPV DNA testing is covered as a cervical cancer screening only when
performed in conjunction with a Pap smear, and only for women aged
30 and older.
To be eligible
for reimbursement as a cervical cancer screening, HPV DNA testing
must be billed in conjunction with a Pap smear that is provided
to a woman aged 30 or older.
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Colorectal
Cancer:
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The following
cancer screenings and frequencies are covered for individuals at average risk for
colon cancer:
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Fecal
Occult Blood Testing (FOBT): Either guaiac-based or immunochemical-based testing
of three consecutive stool samples once every 12 months for beneficiaries
who have attained age 50 (i.e., at least 11 months must have passed
following the month in which the last covered screening fecal-occult
blood test was done).
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Fecal
Immunochemical Testing (FIT-DNA): FDA approved stool DNA
tests (e.g., Cologuard™) once every three years beginning at age
50.
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Proctosigmoidoscopy
or Flexible Sigmoidoscopy: Once every three to five years beginning
at age 50.
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Computed
Tomographic Colongraphy (CTC): Once every five years beginning
at age 50.
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Optical
(Conventional) Colonoscopy: Once every 10 years beginning
at age 50.
A family history
of colorectal cancer or adenomatous polyps increases an individual’s
risk of colon cancer. The following identifies these risk factors
and the cancer screenings and frequencies covered for individuals
at increased risk for colon cancer:
One
or more first-degree relatives diagnosed with sporadic colorectal
cancer or an adenomatous polyp before the age of 60 or in two or
more first-degree relatives at any age. Optical colonoscopy should
be performed every three to five years beginning at age 40 or 10
years earlier than the youngest affected relative, whichever is
earlier.
One or more
first-degree relatives diagnosed with sporadic colorectal cancer
or an adenomatous polyp at age 60 or older, or two second-degree
relatives diagnosed with colon cancer. Either flexible sigmoidoscopy
(once every five years) or optical colonoscopy (once every 10 years)
should be performed beginning at age 40.
Certain
other risk factors put an individual at high risk for colon cancer.
The following identifies these risk factors and the cancer screenings
and frequencies covered for individuals at high risk for colon cancer:
Individuals
with known or suspected Familial Adenomatous Polyposis (FAP). Annual flexible
sigmoidoscopy beginning at age 10 to 12.
Family
history of Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome.
Optical colonoscopy should be performed once every one to two years
beginning at age 20 to 25, or 10 years younger than the earliest
age of diagnosis of colorectal cancer, whichever is earlier.
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Individuals
diagnosed with Inflammatory Bowel Disease (IBD), Chronic Ulcerative
Colitis (CUC), or Crohn’s disease. For these individuals, cancer
risk begins to be significant eight years after the onset of pancolitis
or 10 to 12 years after the onset of left-sided colitis. For individuals
meeting these risk parameters, optical colonoscopy should be performed every
one to two years with biopsies for dysplasia.
Note: The risk factors identified above for colorectal
cancer are those established by the American Cancer Society.
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Prostate
Cancer:
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Rectal
Examination: Digital rectal examination will be offered annually
for all men beginning at age 50 who have at least a 10 year life
expectancy. It should also be offered to begin for men age 45 and
over with a family history of prostate cancer in at least one other
first- degree relative (father, brother, or son) diagnosed with
prostate cancer at an early age (younger than age 65) and to all
African American men aged 45 and over regardless of family history.
Testing should be offered to start at age 40 for men with a family
history of prostate cancer in two or more other family members.
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Prostate-Specific
Antigen (PSA): Annual testing for the following categories
of males may be offered:
1. Men aged
50 years and older.
2. Men aged
45 years and over with a family history of prostate cancer in at
least one other family member.
3.
African American men aged 45 and over regardless of family history.
4.
Men aged 40 and over with a family history of prostate cancer in
two or more other family members.
A
discussion between the beneficiary and his provider on the risks/benefits
of PSA testing is encouraged.
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Testicular
Cancer:
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Physical
Examination: Examination of the testis should be performed
annually for males age 13-39 with a history of cryptorchidism, orchiopexy,
or testicular atrophy.
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Skin Cancer:
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Physical
Examination: Examination of the skin should be performed
for individuals with a family or personal history of skin cancer,
increased occupational or recreational exposure to sunlight, or
clinical evidence of precursor lesions.
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Oral Cavity
and Pharyngeal Cancer:
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Physical
Examination: A complete oral cavity examination should be
part of routine preventive care for adults at high risk due
to exposure to tobacco or excessive amounts of alcohol.
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Thyroid
Cancer:
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Physical
Examination: Palpation for thyroid nodules should be performed
in adults with a history of upper body irradiation.
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Lung Cancer:
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Low-Dose
Computed Tomography: Screening covered annually for persons
55 through 80 years of age with a 30 pack per year history of smoking
who are currently smoking or have quit within the past 15 years.
Screening should be discontinued once the individual has not smoked
for 15 years or develops a health problem significantly limiting
either life expectancy or ability or willingness to undergo curative
lung surgery.
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Immunizations:
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Coverage is
extended for the age appropriate dose of vaccines that meet the
following requirements:
1. The vaccine
has been recommended and adopted by the Advisory Committee on Immunization
Practices (ACIP) for use in the United States; and
2.
The ACIP adopted recommendations have been accepted by the Director
of the Centers for Disease Control and Prevention (CDC) and the
Secretary of Health and Human Services (HHS) and published in a
CDC Morbidity and Mortality Weekly Report (MMWR).
3.
The effective date of coverage for CDC recommended vaccines is the
date ACIP recommendations for the vaccine are published in an MMWR.
Refer
to the CDC’s web site ( http://www.cdc.gov)
for a current schedule of CDC recommended vaccines for use in the
United States. Immunizations
recommended specifically for travel outside the United States are
NOT covered, EXCEPT for immunizations required by dependents of
active duty military personnel who are traveling outside the United
States as a result of an active duty member’s duty assignment, and
such travel is being performed under orders issued by a Uniformed
Service. Claims must include a copy of the travel orders or other
official documentation verifying the official travel requirement.
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Infectious
Diseases:
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Tuberculosis
(TB) Screening: Screen annually, regardless of age, all individuals
at high risk for tuberculosis (as defined by the CDC
using Mantoux tests).
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Rubella
Antibodies: Test females, once, between the ages of 12 and
18, unless documented history of adequate rubella vaccination with
at least one dose of rubella vaccine on or after the first birthday
is documented.
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Hepatitis
B Virus (HBV) Screening: Screen for HBV in individuals at high
risk for infection.
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Hepatitis
C Virus (HCV) Screening: Screen for HCV in individuals at high
risk for infection and as a one-time screening for adults
born between 1945 and 1965.
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Human
Immunodeficiency Virus (HIV) Infection Screening: Screen
for HIV in individuals ages 15-65. Younger adolescents and older
adults who are at increased risk should also be screened.
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Syphilis
Infection Screening: Screen at risk individuals for syphilis
infection.
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Chlamydia
and Gonorrhea Screening: Screen sexually active women age
24 years and younger and older women who are at increased
risk for infection.
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Diabetes
Mellitus (Type II):
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Diabetes
Mellitus (Type II) Screening: Screen adults with a sustained
blood pressure (treated or untreated) greater than 135/80 mmHg.
Screen adults aged 40-70 who are overweight or obese.
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Cardiovascular
Diseases:
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Cholesterol
Screening: Screen children once between the ages of 9 and
11 and again between the ages of 17 and 21. Screen men age 35 and
older. Screen men and women age 20 and older who are at increased
risk for coronary heart disease.
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Blood
Pressure Screening: At least every two years after age six.
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Abdominal
Aortic Aneurysm (AAA): One time AAA screening by ultrasonography
for men, age 65 - 75, who have ever smoked.
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Osteoporosis:
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Osteoporosis
Screening: Screen women for osteoporosis with
bone measurement testing to prevent osteoporotic fractures in women
65 years and older and in post-menopausal women younger than 65
years who are at increased risk of osteoporosis as determined by
a formal clinical assessment tool, including but not limited to,
the Simple Calculated Osteoporosis Risk Estimation (SCORE).
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Intensive
Behavioral Counseling for Sexually Transmitted Infections (STIs):
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Intensive
Behavioral Counseling for STIs: Intensive behavioral counseling
(counseling that lasts more than 30 minutes) for all sexually active
individuals who are at increased risk for STIs is covered
when rendered by a TRICARE authorized provider.
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Intensive,
Multicomponent Behavioral Interventions for Obesity:
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For adults with
a Body Mass Index (BMI) of 30 kg/m2 or higher and for children/adolescents
with a BMI value greater than the 95th percentile, intensive, multicomponent behavioral
interventions to promote sustained weight loss (12 to 26 sessions
in a year) are covered when rendered by a TRICARE authorized provider.
Intensive, multicomponent behavioral interventions include, but
are not limited to: behavioral management activities such as setting
weight-loss goals; diet and physical activity guidance; addressing
barriers to change; active self-monitoring; and, strategies to maintain
lifestyle changes.
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Prenatal
Screening Tests:
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Breast
Pumps, Breast Pump Supplies, and Breastfeeding Counseling:
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Well-Child
Care:
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Other:
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School
Physicals: Physical examinations required in connection with
school enrollment are covered.
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Physical
Examinations Required for Travel Outside the United States – Orders Required:
A physical examination provided when required in the case of a family
member who is traveling outside the United States as a result of
the member’s assignment and such travel is being performed under
orders issued by a Uniformed Service is covered. Claims must include
a copy of the travel orders or other official documentation verifying the
official travel requirement.
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Body Measurement: For
children and adolescents: Height and weight typically is measured
and BMI-for-age calculated and plotted at each primary care visit
using the CDC “Data Table of BMI-for-age Charts”. Children/adolescents
with a BMI value greater than the 85th percentile typically receive
appropriate nutritional and physical activity counseling as part
of the primary care visit. Head circumference typically is measured
through age 24 months.
For adults:
Height and weight typically is measured and BMI calculated at each
primary care visit. Individuals identified with a BMI of 25 or above
typically receive appropriate nutritional and physical activity
counseling as part of primary care visit.
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Vision
Care: Routine eye exam once every two years for retirees
and eligible family members who are enrolled in Prime. Routine eye
exams are not a covered benefit for retirees and eligible family
members who are enrolled in TRICARE Select. Active Duty Family Members
(ADFMs) who are enrolled in Prime or Select may receive a routine
eye exam annually (see Section 6.1) .
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Note: Routine eye examinations are meant
to be more than the standard visual acuity screening test conducted
by the member’s primary care physician through the use of a standard
Snellen wall chart. Self-referral will be allowed for routine eye
examinations since PCMs are incapable of providing this service
(i.e., a Prime beneficiary will be allowed to set up his or her
own appointment for a routine eye examination with any network optometrist
or ophthalmologist).
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Note: TRICARE diabetic beneficiaries may receive
medically necessary eye exams IN ADDITION to the routine eye exams
they receive as a preventive benefit.
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Note: When a beneficiary’s eligibility status
changes from Active Duty Service Member (ADSM) or Prime ADFM to
Prime retiree or retiree family member, the two-year time requirement
between routine eye examinations will start on the date of the eligibility status
change. That is, a Prime retiree or retiree family member will be
eligible for a routine eye examination in the first year of the
status change regardless of whether or not an examination was performed
in the previous year under ADFM eligibility status. The eligibility
status of the beneficiary will dictate the coverage parameters of
the eye examination.
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Hearing
Screening: A hearing evaluation should be a part of routine
examinations for all children, and those with possible hearing impairment
should be referred for appropriate testing.
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Patient
& Parent Education And Counseling:
• Accident &
Injury Prevention;
• Cancer surveillance;
• Depression,
stress, bereavement, & suicide risk assessment;
• Dietary assessment
& nutrition;
• Intimate partner
violence and abuse;
• Physical activity
& exercise;
• Promoting dental
health;
• Risk reduction for skin cancer;
• Safe sexual
practices; and
• Tobacco, alcohol
and substance abuse.
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