Abortions are only covered when the mother’s life is in danger or the pregnancy is the result of rape or incest. The attending physician must certify in writing that the abortion was performed because of one of the above criteria. Oral medications used to end a pregnancy may also be a covered benefit when the pregnancy is a result of rape or incest. Mifeprex and all associated services and supplies are covered only under the medical benefit. Misoprostol and all associated services and supplies may be covered through the medical benefit or through the TRICARE Pharmacy program.
Services or supplies related to spontaneous, missed or threatened abortions and abortions related to ectopic pregnancies may be covered.
Prior authorization is not required, except for active duty service members, however, a benefit review is recommended. The service must be ordered by the primary care manager (PCM) or specialist.
Note: Providers requesting coverage of an abortion can refer to the Letter of Attestation page for additional authorization information.
To receive reimbursement for covered abortions, medical documentation may be required. All claims must include the following:
- The G7 modifier in FL 24D, which is defined as the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening
- One of the following condition codes in FL 10d of the 1500 claim form:
- AA – abortion performed due to rape
- AB – abortion performed due to incest
- AD – abortion performed due to life endangering physical condition