1.0 POLICY
1.1 Medical
contraceptives listed in
Sections 2.1 and
2.2, as well as
female tubal
ligation 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 and
2.2, the family
planning procedures listed below may also be 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 United States (US) Food and Drug Administration
(FDA) approved and used for the labeled indication.
1.2.2 Surgical
sterilization.
Note: Tubal
ligationFemale 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
-TRICARE
Prime or TRICARE Select beneficiaries (i.e., TRICARE for Life (TFL)
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
reversal of a surgical 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 gynecologic examinations,
and related laboratory testing, see the Preventive Services policy.
2.6 The family planning benefit does
not include screening PAP smear tests, routine gynecologic examinations,
including related laboratory testing. However, family planning benefits
may be allowed during an office visit for a screening PAP test.