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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.
Effective July 28, 2022, well
woman exams may include medical contraceptive consultations and
services. Medical contraceptive services include: injections, placement and
removal of intrauterine devices (IUDs), implantable rods, and diaphragm measurements
and fittings.
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SURGICAL STERILIZATION
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Effective January 1, 2023,
cost-sharing for tubal ligation is waived when performed by in-network
TRICARE-authorized providers. Cost-sharing may still apply for tubal
ligations performed by out-of-network providers.
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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 45 (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). FIT of one stool sample once every 12 months beginning
at age 45.
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Fecal Immunochemical
Testing (FIT-DNA): FDA approved stool DNA tests (e.g., Cologuard™)
once every one to three years beginning at age 45.
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Flexible Sigmoidoscopy: Once
every five years beginning at age 45.
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Computed Tomographic
Colonography (CTC): Once every five years beginning at age 45.
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Optical (Conventional)
Colonoscopy: Once every 10 years beginning at age 45.
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Flexible Sigmoidoscopy
with FIT. Flexible Sigmoidoscopy once every 10 years plus annual
FIT beginning at age 45.
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According to the American Cancer
Society (ACS), for screening, people are considered to be at average
risk if they do not have:
• A personal history of colorectal
cancer or certain types of polyps;
• A family history of colorectal
cancer or advanced adenomatous polyps in at least one first degree
relative, or in multiple second degree relatives;
• A personal history of inflammatory
bowel disease (ulcerative colitis or Crohn’s disease);
• A confirmed or suspected hereditary
colorectal cancer syndrome, such as familial adenomatous polyposis
(FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or
Hereditary Non-Polyposis Colorectal Cancer (HNPCC));
• A personal history of getting
radiation to the abdomen (belly) or pelvic area to treat a prior
cancer; or
• Signs
or symptoms of colorectal cancer.
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Note: The ACS no longer maintains
screening guidelines specifically for people at increased or high
risk of colorectal cancer nor does the USPSTF have such recommendations.
A discussion between the beneficiary and their provider to determine if
they are at increased or high risk of
colorectal cancer is encouraged to
decide if they need to start colorectal cancer screening before
age 45, be screened more often, and/or utilize personalized testing
strategies.
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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 50 through 80 years of age
with a 20 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 the 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 Centers
for Disease Control and Prevention (CDC) has published an interim recommendation
on their website at http://www.cdc.gov;
or2. The vaccine has been recommended
and adopted by the Advisory Committee on Immunization Practices
(ACIP) for use in the United States; and the
ACIP adopted recommendations have been accepted by the Director
of the CDC and the Secretary of HHS; and
published in a CDC Morbidity and Mortality Weekly Report (MMWR).
Note:
The effective date of coverage is the earlier of these
two dates.
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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. |
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Immunizations recommended specifically
for travel outside the U.S. are NOT
covered, EXCEPT for immunizations required by dependents of active
duty military personnel who are traveling outside the U.S. 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 U.S. –
Orders Required: A physical examination provided when required
in the case of a family member who is traveling outside the U.S. 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 TRICARE 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 TRICARE Prime or TRICARE 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 TRICARE 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 ADSM or TRICARE Prime
ADFM to TRICARE 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 TRICARE 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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