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Date: _____________________________
Sponsor’s Name: ____________________
Beneficiary’s Name: _________________
Type of Service(s): ___________________
Date of Service(s): ___________________
Last four digits of Sponsor’s
SSN or DoD Benefits Number (DBN): ______________
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PERSONAL
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_____________________________
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To: __________________________
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_____________________________
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Dear _________:
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TRICARE coverage of abortion
services is specifically limited by federal statute. As implemented
by the Department of Defense, TRICARE coverage of abortion services
is limited to when:
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• The life of the mother is at
risk if the fetus is carried to term -- based upon certification
from the attending physician that the patient suffers/suffered a
condition that endangered her life if the fetus were carried to
term; or
• The pregnancy is the result
of an act of rape or incest -- as documented in the patient’s medical
record (effective January 2, 2013).
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This means TRICARE won’t cost-share
on abortions performed for reasons other than those listed above.
Since initial review of your claim(s) gave no indication that this
abortion met the conditions for coverage, TRICARE denied the claim.
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If you believe you do qualify
under one of the exceptions, you may request a Reconsideration of
the denial decision by submitting a written Reconsideration request
to this office within 90 calendar days of the date of this notice. Your
request must include a copy of this notice, a statement outlining
why you disagree with the decision, and any additional information/documentation
from your physician which will support your position.
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If you have any questions concerning
the TRICARE abortion policy, please contact (Contractor Name
and Address).
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Sincerely,
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