3.0 POLICY
3.1 Services
and supplies associated with antepartum care (including well-being
of the fetus), childbirth, postpartum care, and complications of
pregnancy may be covered.
3.2 The maternity
care benefit includes, but is not limited to, the following prenatal
screening tests:
3.2.1 Anemia
Screening:
3.2.2 Asymptomatic
Bacteriuria, Urinary Tract, or Other Infection Screening. Screen
with urine culture for women 12-16 weeks gestation, or at first
prenatal visit, if later.
3.2.3 Gestational
Diabetes Mellitus Screening. Screen women 24-28 weeks pregnant and
those at high risk of developing gestational diabetes.
3.2.4 Hepatitis B Screening. Screen
pregnant women for HBsAG during the prenatal period.
3.2.5 Human Immunodeficiency Virus
(HIV) Infection Screening.
3.2.6 Rh Incompatibility
Screening. Screen all pregnant women and provide follow-up testing
for pregnant women at high risk.
3.2.7 Syphilis Infection Screening.
3.2.8 Other screening tests as recommended
by the United States (US) Preventive Services Task Force.
3.3 Genetic testing is considered
preventive rather than active medical treatment. However, under
the family planning benefit, genetic testing, including testing
done as part of routine prenatal care, is covered when performed
in certain high risk situations. For the purpose of the TRICARE
benefit, genetic testing may include specific tests to detect developmental
abnormalities as well as tests for specific genetic defects.
3.4 The mother and child hospital
Length-of-Stay (LOS) benefit may not be restricted to less than
48 hours following a normal vaginal delivery and 96 hours following
a cesarean section. The decision to discharge prior to those minimum
LOSs must be made by the attending physician in consultation with
the mother.
3.5 Maternity
care for pregnancy resulting from noncoital reproductive procedures
may be cost-shared. Where the contractual arrangements do not specify
an amount for reimbursement for medical expenses, the full amount
of all undesignated payments shall be deemed to be for medical expenses
incurred by the surrogate mother. TRICARE will cost-share on the
remaining balance of otherwise covered benefits related to the surrogate mother’s
medical expenses after the contractually agreed upon arrangement
has been exhausted.
3.6 For pregnancies in which the
TRICARE beneficiary is a surrogate mother, services and supplies
associated with antepartum care, childbirth, postpartum care, and
complications of pregnancy may be cost-shared.
3.7 Tocolysis is a covered benefit.
The off-label use of US Food and Drug Administration (FDA) approved drugs
are subject to requirements specified in
Chapter 8, Section 9.1.
3.8 Progesterone therapy for the
prevention of preterm birth is covered only for weekly injections
of 17 alpha-hydroxyprogesterone caproate between 16 and 36 weeks
of gestation for pregnant women with a documented history of a previous
spontaneous birth at less than 37 weeks of gestation.
4.0 EXCLUSIONS
4.1 Oral progesterone
therapy or injections of 17 alpha-hydroxyprogesterone caproate are NOT covered
for other high risk factors for preterm birth, including, but not
limited to multiple gestations, short cervical length, or positive
fetal tests for cervicovaginal fetal fibronectin.
4.2 Services and supplies related
to noncoital reproductive procedures.
4.3 Home Uterine
Activity Monitoring (HUAM), telephonic transmission of HUAM data,
or HUAM-related telephonic nurse or physician consultation for the
purpose of monitoring suspected or confirmed pre-term labor is unproven.
4.4 Subcutaneous terbutaline pump
and home use of maintenance subcutaneous terbutaline to suppress labor
is unproven.
4.5 Lymphoctye or paternal leukocyte
immunotherapy in the treatment of recurrent spontaneous fetal loss
is unproven.
4.6 Salivary estriol test for preterm
labor is unproven (Current Procedural Terminology (CPT) code 82677).