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 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: 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-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 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 (PAPPap) smear tests, human
papillomavirus (HPV) testing, routine gynecologic examinations,
and related laboratory testing, see the Preventive Services policy.
2.6 The family planning benefit does
not include cervical cancer screening PAP
smear (i.e., Pap tests and/or HPV
testing), routine gynecologic examinations, including
related laboratory testing. However, family planning benefits may
be allowed during an office visit for a cervical
cancer screening PAP test.
