1.0 POLICY
1.1 Medical contraceptives listed
in
Sections 2.1 and
2.2, as well
as
female tubal
sterilization (see note
below), are covered as the clinical preventive services benefit.
1.2 In addition to the medical
contraceptives listed in
Section 2.1,
the family planning procedures listed below may be also cost-shared:
1.2.1 Prescription contraceptives,
including diaphragms received in the pharmacy setting, and prescription
contraceptives used as emergency contraceptives.
Note: Implantable prescription contraceptives
are covered if the U.S. Food and Drug Administration (FDA) approved
and used for the labeled indication.
1.2.2 Surgical sterilization.
Note: Female tubal
sterilization procedures
are covered with no-cost sharing when performed by an in-network
provider for TRICARE Prime and TRICARE Select beneficiaries, effective
January 1, 2023. However, cost-sharing may apply when performed
by an out-of-network provider or when provided to non-Prime or Select
beneficiaries (i.e., TRICARE for Life beneficiaries). See
Section 2.2.
2.0 EXCLUSIONS
2.1 Prophylactics
(condoms).
2.2 Spermicidal foams, jellies,
and sprays not requiring a prescription.
2.3 Services
and supplies related to noncoital reproductive technologies, including
but not limited to artificial insemination (including cost related
to donors and semen banks), In Vitro Fertilization (IVF) and Gamete
Intrafallopian Transfer (GIFT).
2.4 Male
reversal
of a surgical sterilization and
reversal
of a female
tubal sterilization
procedure, except medically necessary reversal of surgical sterilization
for the treatment of a disease or injury (see
Chapter 4, Sections 15.1 and
17.1).
2.5 For routine
screening Papanicolaou (PAP) smear tests, routine gynelogic examinations,
and related laboratory testing, see the Preventive Services policy.
2.6 The family planning benefit
does not include screening PAP smear tests, routine gynelogic examinations,
including related laboratory testing. However, family planning benefits
may be allowed during an office visit for a screening PAP test.