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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 is 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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FEMALE TUBAL STERILIZATION
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Effective January 1,
2023, cost-sharing for female tubal sterilization is waived when
performed by in-network TRICARE-authorized providers. Cost-sharing
may still apply for female tubal sterilizations performed by out-of-network
providers.
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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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Breast Cancer Gene 1
(BRCA1) or Breast Cancer Gene 2 (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.
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.
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 Papanicolaou (Pap) smear testing for
cervical neoplasms and premalignant lesions.
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Pap 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 age 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 age 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.
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 age 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 age 50 years and older.
2. Men age 45 years and over
with a family history of prostate cancer in at least one other family member.
3. African American men age 45
and over regardless of family history.
4. Men age 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;
or 2. The vaccine has been recommended
and adopted by the Advisory Committee on Immunization Practices
(ACIP) for use in the US; and the ACIP adopted recommendations have
been accepted by the Director of the CDC and the Secretary of DHHS
and published in a CDC Morbidity and Mortality Weekly Report (MMWR).
Note: The effective date of coverage
is the earlier of these two dates.
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 family members 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 age
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 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).
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).
Note: TRICARE diabetic beneficiaries
may receive medically necessary eye exams IN ADDITION to the routine
eye exams they receive as a preventive benefit.
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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