Pain management or opioid therapy for chronic pain is a limited benefit. Although non-pharmacologic therapy is the preferred treatment for chronic pain, opioid therapy can be considered for coverage when medically necessary. The Centers for Disease Control and Prevention (CDC) has written the Guideline for Prescribing Opioids for Chronic Pain to assist providers in determining the appropriate time to introduce and ways to manage opioids for the treatment of pain.
See also Pharmacy and Medication or Pharmaceuticals.
Cancer screening Pap smears, also known as a Pap test, are covered for female beneficiaries beginning at age 21. The frequency of the screening Pap smears is at the discretion of the beneficiary and provider; however they should be performed at least once every three years. Women under age 21 should not be screened regardless of the age of sexual initiation or other risk factors. View preventive services costs when performed during a health promotion and disease prevention exam. There may be costs for a Pap test if performed due to a diagnosis. See cost information for lab and X-ray services and office visits.
Note: TRICARE allows for a 30-day grace period prior to due date of the next Pap smear.
Partial Hospitalization Program (PHP)
Partial hospitalization programs (PHP) for mental health and substance use disorder are a limited benefit. More>>
Not a covered benefit.
Personal, comfort or convenience items
Not a covered benefit.
The TRICARE Pharmacy Program provides prescription medication to TRICARE beneficiaries. More >>
Physical Rehabilitation (Acute Inpatient)
Acute inpatient admission for physical rehabilitation is a covered benefit. TRICARE Prime beneficiaries (including active duty service members) require an approval from Health Net Federal Services, LLC prior to admission.
TRICARE Select beneficiaries do not require an approval; however, notification of admissions and discharge dates must be submitted by the next business day following the admission and discharge.
- The beneficiary must meet a minimum requirement of three hours per day of at least two different types of therapy (for example, physical and occupational therapy).
- If the beneficiary does not meet the minimum requirements at the initial goal length of stay, the entire admission may not be covered.
Clinical information will be requested to extend the initial assigned length of stay. This is a separate benefit from Skilled Nursing Facility (SNF) care and hospitalization.
Physical therapy is covered to aid in the recovery from disease or injury to help the patient in attaining greater self-sufficiency, mobility, and productivity by improving muscle strength, joint motion, coordination, and endurance. More >>
Physicals are covered in limited circumstances. More >>
Positron Emission Tomography (PET) Scan
Positron Emission Tomography (PET) scans are a limited benefit. More>>
Preventive services are periodic health screenings or assessments and are not directly related to a specific illness, injury or set of symptoms. More >>
Private Hospital Rooms
Not a covered benefit unless ordered for medical reasons or a semi-private room is not available.
Prostate Cancer Screening
One prostate cancer screening every 12 months may be covered when provided as part of a clinical preventive exam. The screening includes a digital rectal exam and prostate-specific antigen screening for:
- Men age 40 and older with a family history of prostate cancer in two or more other family members.
- Men age 45 and older with a family history of prostate cancer in at least one other family member.
- All African-American men age 45 and older regardless of family history.
- All men age 50 and older.
Prosthetics, also known as prosthesis and related supplies are a covered benefit. More >>
Psychoanalysis (CPT® 90845) is a limited benefit. Prior authorization is required for all beneficiaries.
Psychological testing and assessment is a covered benefit when medically or psychologically necessary and is provided in conjunction with otherwise covered psychotherapy or as a required part of the assessment and reassessment process for applied behavior analysis.
An approval from Health Net Federal Services, LLC (HNFS) is required for active duty service members (ADSMs). All other TRICARE Prime beneficiaries (excluding ADSMs) do not require an approval when seeing a network provider. TRICARE Prime beneficiaries must have an approval from HNFS to a non-network provide unless they choose to use their Point of Service option. TRICARE Select beneficiaries do not require an approval from HNFS.
CPT® code ranges 96130–96136 and 96146 are generally limited to 22 units. Additional units require documentation to support the medical necessity. CPT code 96137 is limited to 11 units per day.
Psychological testing is not covered when used for academic or vocational placement or assessment, when used to evaluate non-covered disorders (for example, learning disorders) or when used to assess intelligence in the absence of a need to diagnose or plan treatment for a covered psychiatric disorder.
Outpatient psychotherapy that is medically or psychologically necessary to treat a covered mental health disorder is a covered benefit. More >>
Pulmonary rehabilitation services provided as part of a treatment program on an inpatient or outpatient basis may be a covered benefit. The pulmonary rehabilitaion services must be proven treatment for the patient's condition. Examples of proven indications are: cardiopulmonary or pulmonary rehabilitation for pre- and post-lung transplant patients, severe Chronic Obstructive Pulmonary Disease (COPD) on an inpatient basis; and moderate and severe COPD on an outpatient basis.
If covered, the setting where the services are provided will determine costs; outpatient office setting or inpatient hospital setting.