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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 2, Figure 18.2-1. |
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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 (ACS).
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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 ACS.
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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 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, cancerPap
Smears: 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 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 50 45.
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Proctosigmoidoscopy
or Flexible Sigmoidoscopy: Once every three
to five years beginning at age 50 45.
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Computed Tomographic Colongraphy Colonography (CTC): Once
every five years beginning at age 50 45.
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Optical (Conventional)
Colonoscopy: Once every 10 years beginning
at age 45.
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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 ACS.
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Flexible Sigmoidoscopy
with FIT: Flexible Sigmoidoscopy once
every 10 years plus annual FIT beginning at age 45.
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 colon 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 and symptoms of
colorectal cancer.
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 in order to determine if they need to start
colorectal 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 55 50 through
80 years of age with a 30 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 vaccine has been recommended
and adopted by the Advisory Committee on Immunization Practices
(ACIP) for use in the US; 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 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 website
( http://www.cdc.gov)
for a current schedule of CDC recommended vaccines for use in the
US. Immunizations recommended specifically
for travel outside the US are NOT covered, EXCEPT for immunizations
required by dependents of active duty military personnel who are
traveling outside the US 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 US – Orders Required: A physical examination
provided when required in the case of a family member who is traveling
outside the US 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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