HEALTH PROMOTION AND DISEASEPREVENTION (HP&DP) EXAMINATIONS
For ages six year and or older:One HP&DP examination is covered annually.
WELL WOMAN EXAMINATIONS
HP&DP exams for the purposeof a well woman exam are covered annually for female beneficiariesunder age 65. If the primary care clinician determines that a patientrequires additional well woman visits to obtain all necessary recommendedpreventive services that are age and developmentally appropriate,these may be provided without copay and subject to reasonable medicalmanagement.
Effective July 28, 2022, wellwoman exams may include medical contraceptive consultations andservices. Medical contraceptive services include: injections, placement andremoval of intrauterine devices (IUDs), implantable rods, and diaphragm measurementsand fittings.
FEMALETUBAL STERILIZATION
Effective January 1, 2023, cost-sharingfor female tubal sterilization iswaived when performed by in-network TRICARE-authorized providers.Cost-sharing may still apply for female tubal sterilizations performedby out-of-network providers.
TARGETED CLINICAL PREVENTIVESERVICES
The following clinical preventiveservices may be performed during either an HP&DP exam or a wellwoman exam.
Breast Cancer:
Clinical Breast Examination(CBE): A CBE may be performed during a covered HP&DP exam.
BRCA1 or BRCA2 GeneticCounseling and Testing: Genetic counseling rendered by a TRICARE-authorizedprovider that precedes BRCA1 or BRCA2 gene testing is covered for womenwho are identified as high risk for breast cancer bytheir primary care clinician.
BRCA1 or BRCA2 gene testingis covered for women who meet the coverage guidelines outlined inthe TRICARE Operations Manual (TOM), Chapter 18, Section 3, Figure 18.3-1.
Screening Mammography: Coveredannually for all women beginning at age 40. Covered annually beginningat age 30 for women who have a 15% or greater lifetime risk of breastcancer (according to risk assessment tools based on family historysuch 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 breastswhen viewed by mammogram;
3. *Known BRCA1 or BRCA2 genemutation;
4. *First-degree relative (parent,child, sibling) with a BRCA1 or BRCA2 gene mutation, and have nothad genetic testing themselves;
5. Radiation therapy to thechest between the ages of 10 and 30 years; or
6. History of Li-Fraumeni,Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degreerelative with a history of one of these syndromes.
Note: The riskfactors identified above for screening mammography are those established bythe American Cancer Society.
Breast Screening MagneticResonance Imaging (MRI): Covered annually, in addition to theannual screening mammogram, beginning at age 30 for women who havea 20% or greater lifetime risk of breast cancer (according to riskassessment tools based on family history such as the Gail model,the Claus model, and the Tyrer-Cuzick model), or who have any ofthe following risk factors:
1. *Known BRCA1 or BRCA2 genemutation;
2. First-degree relative (parent,child, sibling) with a BRCA1 or BRCA2 gene mutation, and have nothad genetic testing themselves;
3. Radiation to the chest betweenthe ages of 10 and 30; or
4. History of LiFraumeni, Cowden,or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relativewith a history of one of these syndromes.
Note: The riskfactors identified above for breast cancer screening MRI are those establishedby the American Cancer Society.
Cervical Cancer
Pelvic Examination:A pelvic examination should be performed as part of a well woman examand in conjunction with Pap smear testing for cervical neoplasmsand premalignant lesions.
Pap Smears: Fordates of service prior to May 8, 2015, cancer screening Pap smearsshould be performed for women who are at risk for sexually transmittablediseases, women who have or have had multiple sexual partners (orif their partner has or has had multiple sexual partners), womenwho smoke cigarettes, and women 18 years of age and older when providedunder the terms and conditions contained in the guidelines adoptedby the Director, Defense Health Agency (DHA). The frequency of thescreening Pap smears will be at the discretion of the patient andclinician but not less frequent then every three years.
For dates of service on orafter May 8, 2015, cancer screening Pap smears are covered for femalebeneficiaries beginning at age 21. Women under age 21 should notbe screened regardless of the age of sexual initiation or otherrisk factors. The frequency of screening Pap smears may be at thediscretion of the patient and clinician; however, screening Pap smearsshould not be performed less frequently than once every three years.
Human Papillomavirus(HPV) Deoxyribonucleic Acid (DNA) Testing: HPV DNA testing iscovered as a cervical cancer screening only when performed in conjunctionwith a Pap smear, and only for women aged 30 and older.
To be eligible for reimbursem*ntas a cervical cancer screening, HPV DNA testing must be billed inconjunction with a Pap smear that is provided to a woman aged 30or older.
Colorectal Cancer:
The following cancer screeningsand frequencies are covered for individuals at average risk forcolon cancer:
Fecal Occult Blood Testing(FOBT): Either guaiac-based or immunochemical-based testingof three consecutive stool samples once every 12 months for beneficiarieswho have attained age 45 (i.e., at least 11 months must have passedfollowing the month in which the last covered screening fecal-occultblood test was done).
Fecal ImmunochemicalTesting (FIT). FIT of one stool sample once every 12 months beginningat age 45.
Fecal ImmunochemicalTesting (FIT-DNA): FDA approved stool DNA tests (e.g., Cologuard™)once every one to three years beginning at age 45.
Flexible Sigmoidoscopy: Onceevery five years beginning at age 45.
Computed TomographicColonography (CTC): Once every five years beginning at age 45.
Optical (Conventional)Colonoscopy: Once every 10 years beginning at age 45.
Flexible Sigmoidoscopywith FIT. Flexible Sigmoidoscopy once every 10 years plus annualFIT beginning at age 45.
According to the American CancerSociety (ACS), for screening, people are considered to be at averagerisk if they do not have:
•A personal history of colorectalcancer or certain types of polyps;
•A family history of colorectalcancer or advanced adenomatous polyps in at least one first degreerelative, or in multiple second degree relatives;
•A personal history of inflammatorybowel disease (ulcerative colitis or Crohn’s disease);
•A confirmed or suspected hereditarycolorectal cancer syndrome, such as familial adenomatous polyposis(FAP) or Lynch syndrome (hereditary non-polyposis colon cancer orHereditary Non-Polyposis Colorectal Cancer (HNPCC));
•A personal history of gettingradiation to the abdomen (belly) or pelvic area to treat a priorcancer; or
•Signsor symptoms of colorectal cancer.
Note:The ACS no longer maintainsscreening guidelines specifically for people at increased or highrisk of colorectal cancer nor does the USPSTF have such recommendations.A discussion between the beneficiary and their provider to determine ifthey are at increased or high risk ofcolorectal cancer is encouraged to decide if they need to startcolorectal cancer screening before age 45, be screened more often,and/or utilize personalized testing strategies.
Prostate Cancer:
Rectal Examination:Digital rectal examination will be offered annually for all men beginningat age 50 who have at least a 10 year life expectancy. It shouldalso be offered to begin for men age 45 and over with a family historyof prostate cancer in at least one other first- degree relative(father, brother, or son) diagnosed with prostate cancer at an earlyage (younger than age 65) and to all African American men aged 45and over regardless of family history. Testing should be offeredto start at age 40 for men with a family history of prostate cancerin two or more other family members.
Prostate-Specific Antigen(PSA): Annual testing for the following categories of males maybe offered:
1. Men aged 50 years and older.
2. Men aged 45 years and overwith a family history of prostate cancer in at least one other familymember.
3. African American men aged45 and over regardless of family history.
4. Men aged 40 and over witha family history of prostate cancer in two or more other familymembers.
A discussion between the beneficiaryand his provider on the risks/benefits of PSA testing is encouraged.
Testicular Cancer:
Physical Examination:Examination of the testis should be performed annually for males age13-39 with a history of cryptorchidism, orchiopexy, or testicularatrophy.
Skin Cancer:
Physical Examination:Examination of the skin should be performed for individuals with afamily or personal history of skin cancer, increased occupationalor recreational exposure to sunlight, or clinical evidence of precursorlesions.
Oral Cavity and Pharyngeal Cancer:
Physical Examination:A complete oral cavity examination should be part of routine preventivecare for adults at high risk due to exposure to tobaccoor excessive amounts of alcohol.
Thyroid Cancer:
Physical Examination:Palpation for thyroid nodules should be performed in adults with ahistory of upper body irradiation.
Lung Cancer:
Low-Dose Computed Tomography:Screening covered annually for persons 50 through 80 years of agewith a 20 pack per year history of smoking who are currently smokingor have quit within the past 15 years. Screening should be discontinuedonce the individual has not smoked for 15 years or develops a healthproblem significantly limiting either life expectancy or the abilityor willingness to undergo curative lung surgery.
Immunizations:
Coverage is extended for theage appropriate dose of vaccines that meet the following requirements:
1. The Centers for DiseaseControl and Prevention (CDC) has published an interim recommendationon their website at http://www.cdc.gov;or
2. The vaccine has been recommendedand adopted by the Advisory Committee on Immunization Practices(ACIP) for use in the United States; and the ACIP adopted recommendationshave been accepted by the Director of the CDC and the Secretaryof HHS; and published in a CDC Morbidity and Mortality Weekly Report(MMWR).
Note:The effective date of coverageis the earlier of these two dates.
Refer to the CDC’s web site(http://www.cdc.gov)for a current schedule of CDC recommended vaccines for use in theUnited States.
Immunizations recommended specificallyfor travel outside the U.S. are NOT covered, EXCEPT for immunizationsrequired by dependents of active duty military personnel who aretraveling outside the U.S. as a result of an active duty member’sduty assignment, and such travel is being performed under ordersissued by a Uniformed Service. Claims must include a copy of thetravel orders or other official documentation verifying the official travelrequirement.
Infectious Diseases:
Tuberculosis (TB) Screening:Screen annually, regardless of age, all individuals at high risk fortuberculosis (as defined by the CDC using Mantoux tests).
Rubella Antibodies:Test females, once, between the ages of 12 and 18, unless documentedhistory of adequate rubella vaccination with at least one dose ofrubella vaccine on or after the first birthday is documented.
Hepatitis B Virus (HBV)Screening: Screen for HBV in individuals at high risk for infection.
Hepatitis C Virus (HCV)Screening: Screen for HCV in individuals at high risk for infectionand as a one-time screening for adults born between 1945 and 1965.
Human ImmunodeficiencyVirus (HIV) Infection Screening: Screen for HIV in individualsages 15-65. Younger adolescents and older adults who are at increasedrisk should also be screened.
Syphilis Infection Screening:Screen at risk individuals for syphilis infection.
Chlamydia and GonorrheaScreening: Screen sexually active women age 24 years and youngerand older women who are at increased risk for infection.
Diabetes Mellitus (TypeII):
Diabetes Mellitus (TypeII) Screening: Screen adults with a sustained blood pressure (treatedor untreated) greater than 135/80 mmHg. Screen adults aged 40-70who are overweight or obese.
Cardiovascular Diseases:
Cholesterol Screening:Screen children once between the ages of 9 and 11 and again betweenthe ages of 17 and 21. Screen men age 35 and older. Screen men andwomen age 20 and older who are at increased risk forcoronary heart disease.
Blood Pressure Screening:At least every two years after age six.
Abdominal Aortic Aneurysm(AAA): One time AAA screening by ultrasonography for men,age 65 - 75, who have ever smoked.
Osteoporosis:
Osteoporosis Screening:Screen women for osteoporosis with bone measurement testing to preventosteoporotic fractures in women 65 years and older and in post-menopausalwomen younger than 65 years who are at increased risk of osteoporosisas determined by a formal clinical assessment tool, including butnot limited to, the Simple Calculated Osteoporosis Risk Estimation(SCORE).
Intensive Behavioral Counselingfor Sexually Transmitted Infections (STIs):
Intensive BehavioralCounseling for STIs: Intensive behavioral counseling (counseling thatlasts more than 30 minutes) for all sexually active individualswho are at increased risk for STIs is covered whenrendered by a TRICARE authorized provider.
Intensive, Multicomponent BehavioralInterventions for Obesity:
For adults with a Body MassIndex (BMI) of 30 kg/m2 or higher and for children/adolescents witha BMI value greater than the 95th percentile, intensive, multicomponent behavioralinterventions to promote sustained weight loss (12 to 26 sessionsin a year) are covered when rendered by a TRICARE authorized provider.Intensive, multicomponent behavioral interventions include, butare not limited to: behavioral management activities such as settingweight-loss goals; diet and physical activity guidance; addressingbarriers to change; active self-monitoring; and, strategies to maintainlifestyle changes.
Prenatal Screening Tests:
See Chapter 4, Section 18.1.
Breast Pumps, BreastPump Supplies, and Breastfeeding Counseling:
See Chapter 8, Section 2.6.
Well-Child Care:
See Section 2.5.
Other:
School Physicals:Physical examinations required in connection with school enrollment arecovered.
Physical ExaminationsRequired for Travel Outside the U.S. – Orders Required: A physicalexamination provided when required in the case of a family memberwho is traveling outside the U.S. as a result of the member’s assignmentand such travel is being performed under orders issued by a UniformedService is covered. Claims must include a copy of the travel ordersor other official documentation verifying the official travel requirement.
Body Measurement: Forchildren and adolescents: Height and weight typically is measuredand BMI-for-age calculated and plotted at each primary care visitusing the CDC “Data Table of BMI-for-age Charts”. Children/adolescentswith a BMI value greater than the 85th percentile typically receiveappropriate nutritional and physical activity counseling as partof the primary care visit. Head circumference typically is measuredthrough age 24 months.
For adults: Height and weighttypically is measured and BMI calculated at each primary care visit.Individuals identified with a BMI of 25 or above typically receiveappropriate nutritional and physical activity counseling as partof primary care visit.
Vision Care: Routineeye exam once every two years for retirees and eligible family memberswho are enrolled in TRICARE Prime. Routine eye exams are not a coveredbenefit for retirees and eligible family members who are enrolledin TRICARE Select. Active Duty Family Members (ADFMs) who are enrolledin TRICARE Prime or TRICARE Select may receive a routine eye examannually (see Section 6.1).
Note:Routineeye examinations are meant to be more than the standard visual acuity screeningtest conducted by the member’s primary care physician through theuse of a standard Snellen wall chart. Self-referral will be allowedfor routine eye examinations since PCMs are incapable of providingthis service (i.e., a TRICARE Prime beneficiary will be allowedto set up his or her own appointment for a routine eye examinationwith any network optometrist or ophthalmologist).
Note:TRICAREdiabetic beneficiaries may receive medically necessary eye examsIN ADDITION to the routine eye exams they receive as a preventivebenefit.
Note:When abeneficiary’s eligibility status changes from ADSM or TRICARE PrimeADFM to TRICARE Prime retiree or retiree family member, the two-yeartime requirement between routine eye examinations will start onthe date of the eligibility status change. That is, a TRICARE Primeretiree or retiree family member will be eligible for a routineeye examination in the first year of the status change regardlessof whether or not an examination was performed in the previous yearunder ADFM eligibility status. The eligibility status of the beneficiarywill dictate the coverage parameters of the eye examination.
Hearing Screening:A hearing evaluation should be a part of routine examinations forall children, and those with possible hearing impairment shouldbe referred for appropriate testing.
Patient & ParentEducation And Counseling:
•Accident & Injury Prevention;
•Cancer surveillance;
•Depression, stress, bereavement,& suicide risk assessment;
•Dietary assessment & nutrition;
•Intimate partner violence andabuse;
•Physicalactivity & exercise;
•Promoting dental health;
•Risk reduction for skin cancer;
•Safe sexual practices; and
•Tobacco, alcohol and substanceabuse.
