Not a covered benefit; for example, camps for diabetes or weight loss.
Cancer Clinical Trials
Cancer clinical trials may be cost-shared for all TRICARE-eligible beneficiaries participating in NCI (National Cancer Institute) sponsored Phase I, Phase II and Phase III studies for the prevention, screening, early detection and treatment of cancer. More >>
Hospital-based acute rehabilitation, including inpatient hospitalization and up to 36 outpatient sessions per cardiac event, may be covered. More >>
Cardiovascular disease screenings are a covered benefit, and include cholesterol and blood pressure checks. Cholesterol testing is a covered benefit once between the ages of 9 and 11 and again between the ages of 17 and 21. Screen men age 35 and older, and screen men and women age 20 and older who are at increased risk for coronary heart disease. TRICARE recommends blood pressure checks for children at least every two years after age six. View preventive services costs if rendered during a clinical preventive exam. There may be a cost-share/copayment if rendered during an office visit for a medical condition.
Chelation therapy is covered if the chelating agent is approved by the U.S. Food and Drug Administration (FDA) and used for an FDA-approved indication. Chelation therapy is a covered benefit when used to treat heavy metal toxicity, such as lead poisoning. Chelation therapy is not a covered benefit when used to treat multiple sclerosis, arthritis, hypoglycemia, diabetes, arteriosclerosis, malaria, cancer, Alzheimer's disease, autism spectrum disorders, or any other condition for which chelation therapy is not FDA-approved.
Chemotherapy and Radiation Treatment
Chemotherapy and radiation for the treatment of cancer is a covered benefit. Chemotherapy agents must be approved by the U.S. Food and Drug Administration (FDA) and used for an FDA-approved indication or considered a standard of care. See also Cancer Clinical Trials.
Not a covered benefit; however, active duty service members may receive chiropractic services at select military treatment facilities. See chiropractic care for active duty service members for more information. Beneficiaries should contact their primary care provider to discuss and order any necessary services recommended by a chiropractor.
Chronic Fatigue Syndrome Treatment
Not a covered benefit.
Male circumcision is covered as part of the inpatient services for a newborn. Circumcisions performed outside of the newborn period (day 0 through day 30 of age) due to medical complications at birth or newborn period, that prevented performing the circumcision within the newborn period, may be covered up to 30 days after discharge. Circumcisions performed after the newborn period without medical complications at birth, may be covered if medically necessary and otherwise authorized for benefits. Adult circumcisions may be covered if medically necessary and cost-shares are based on the type of location where the service is provided.
If a circumcision is performed after the newborn has been discharged from the hospital and is provided in an office visit setting, it is cost-shared with office visit costs. If it is performed in an outpatient hospital or ambulatory surgery facility it is cost-shared with ambulatory surgery costs.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
Implantation, to include the implants and the external speech processor device, is a limited benefit. More >>
Colonoscopy or Flexible Sigmoidoscopy
Routine colonoscopy, proctosigmoidoscopy, or sigmoidoscopy performed for colorectal cancer screening, in the absence of cancer or other presenting signs, is a limited benefit under TRICARE. More >>
Colorectal Cancer Screenings
Colorectal cancer screenings are a covered benefit. The following screenings are covered for those at average risk starting at age 45:
- fecal occult blood test: Once every 12 months
- fecal immunochemical testing (FIT): One stool sample every 12 months
- FIT-DNA: FDA-approved stool DNA tests (e.g. Cologuard™) once every one to three years
- flexible sigmoidoscopy: Once every five years
- computed tomographic colonography: Once every five years
- colonoscopy: Every 10 years
- flexible sigmoidoscopy with annual FIT: Once every 10 years
Note: TRICARE allows for a 30-day grace period prior to due date of the next screening.
According to the American Cancer Society (ACS), for screening, people are considered to be at average risk if they do not have:
- A personal history of colorectal cancer or certain types of polyps;
- A family history of colorectal cancer or advanced adenomatous polyps in at least one first degree relative, or in multiple second degree relatives;
- A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease);
- A confirmed or suspected hereditary colorectal cancer syndrome;
- A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer; or
- Signs or symptoms of colorectal cancer.
The American Cancer Society and United States Preventive Services Task Force no longer offer guidelines specifically for people at increased or high risk of colorectal cancer. Providers are encouraged to discuss with beneficiaries who may be at increased or high risk as to whether they need to start colorectal cancer screening before age 45, be screened more often, and/or use personalized testing strategies.
Complications from Non-Covered Services
Complications from non-covered services are only covered when the initial non-covered treatment was provided in a military treatment facility (MTF), authorized by the MTF Commander and the MTF was unable to provide the necessary treatment for the complication. All other treatment of complications, infection from non-TRICARE covered services or removal of non-covered implants are not a covered benefit.
Computerized Dynamic Posturography (CDP)
Computerized dynamic posturography (CDP), also known as moving platform posturography or dynamic posturography, is not a covered benefit.
Consultations are a covered benefit. Per the American Psychological Association (APA) and the 2017 American Medical Association (AMA) CPT® 2017 policies, “a consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s care or for the care of a specific condition or problem.”
If the referring physician does not make the request in writing and a report to the first physician is not requested, or if treatment is transferred to the consulting physician and the transfer is accepted prior to seeing the patient, the visit is not a consultation. Examples of non‐consultation visits include when a primary care manager refers a patient to a dermatologist for a skin disorder and asks the specialist to assume responsibility for the treatment, and when a patient visits a physician for the sole purpose of obtaining a second opinion from another provider.
CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Continuous Positive Airway Pressure (CPAP) Machine
Continuous Positive Airway Pressure (CPAP) machines, also known as respiratory assist devices, are considered durable medical equipment (DME). CPAP machines are a limited benefit. More>>
Non-prescription contraceptives are not a covered benefit. See birth control.
Cord Blood Banking
TRICARE does not cover cord blood banking for healthy newborns.
Umbilical cord blood stem cell transplantation (UCBT) – when stem cells are harvested from the umbilical cord and placenta, and later infused into the patient's bloodstream – is a limited benefit that requires prior authorization. Separate outpatient costs may apply or they may be included in the inpatient hospital costs.
Cosmetic, Plastic or Reconstructive Surgery
Cosmetic, plastic or reconstructive surgery is a limited benefit. It may be covered to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance after severe disfigurement after cancer surgery or breast reconstruction after cancer surgery.
If covered, the setting where the services are provided will determine cost; outpatient office setting, ambulatory surgery setting or inpatient hospital setting.
COVID-19 Clinical Trials
COVID-19 clinical trials may be cost-shared for beneficiaries participating in the National Institute of Allergy and Infectious Diseases (NIAID)-sponsored studies. Phase I, II, III and IV studies for the prevention, screening, early detection, and treatment of COVID-19 and its associated aftereffects (for example, cardiac and pulmonary complications) are included.
TRICARE beneficiaries may be eligible for NIAID-sponsored protocols when treating providers indicate standard treatment has been or would be ineffective, does not exist or there is no superior non-investigational treatment alternative.
Providers must notify HNFS of patients’ COVID-19 clinical trial participation via fax at 1-844-818-9289. Include any supporting documentation, the National Clinical Trial (NCT) number and a local point of contact. For additional questions, call our Case/Care Management Line at 1-844-524-3578, option 5.
The following coverage applies:
- Medical care and testing required to determine eligibility, including the evaluation for eligibility at the institution conducting the NIAID-sponsor trial.
- Medical care required as a result of participation in the study, including necessary follow-up care and testing that takes place after the period of active treatment on protocol is completed. This includes all approved pharmaceutical drugs (except for the NIAID-funded investigational agents) and all inpatient and outpatient care, diagnostic, laboratory, rehabilitation, and home health services not otherwise reimbursed under a NIAID grant program.
- Beneficiaries enrolled in an eligible COVID-19 clinical trial during the national emergency will remain covered for the duration of that clinical trial, even if the national emergency has ended, so long as TRICARE requirements are met.
Beneficiaries must follow authorization requirements based on his/her TRICARE plan and the type of service they are receiving under this trial. The institutional and individual providers must be TRICARE-authorized and treatments must be NIAID-sponsored Phase I, II, III, and IV protocols.
The type of service or setting where the services are provided will determine costs.
Eligible clinical trials can be found visiting the U.S. National Library of Medicine Database at ClinicalTrials.gov and the NIAID website at www.niaid.nih.gov.
COVID-19 diagnostic and antibody (serology) testing is a covered benefit when medically necessary. More >>
COVID-19 vaccines are a covered benefit. More >>
Cranial Orthotic Device or Molding Helmet
Cranial orthotic devices, or molding helmets, are covered only for postoperative use for infants (3–18 months) who have undergone surgical correction of craniosynostosis and have moderate-to-severe residual cranial deformities.
Cranial orthotic devices, or molding helmets, are not a covered benefit for treatment of nonsynostotic positional plagiocephaly or when used alone to treat craniosynostosis.
Custodial care is a limited benefit for active duty service members. This care is not a covered benefit for all other beneficiaries. Custodial care provides support services for individuals who cannot care for themselves and do not require skilled medical care. Patients seeking these services may include those with a degenerative condition such as Parkinson's or ALS, a prolonged illness like cancer or a cognitive disorder like Alzheimer's. These support services may include activities of daily living such as dressing, bathing and using the bathroom.