Abortion Coverage Guidelines for Your TRICARE Patients
Tuesday, August 9, 2022
Following the Supreme Court’s recent decision in Dobbs v. Jackson Women’s Health Organization, many providers may have questions about what the ruling means for TRICARE. The Supreme Court’s decision does not prohibit TRICARE from continuing to cover abortion services in accordance with federal law. Health Net Federal Services, LLC (HNFS) offers the following refresher on TRICARE’s coverage guidelines for abortion services. Visit our Benefits A-Z Abortion page and www.tricare.mil/CoveredServices for additional benefit details.
Is abortion covered by TRICARE?
Federal law prohibits the U.S. Department of Defense from performing or paying for abortions except in cases when the life of the mother would be endangered should the fetus be carried to term or when the pregnancy is the result of rape or incest. Important: The attending health care provider must document in the patient’s medical record that an abortion was performed for one of the above criteria. Attach a letter of attestation (LOA) to a claim using our LOA template.
Is medication abortion covered by TRICARE?
Oral medications used to end a pregnancy are a TRICARE-covered service when a pregnancy is caused by an act of rape or incest. Current FDA requirements allow for coverage of Mifeprex and all associated services and supplies 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, administered by Express Scripts. Visit www.militaryrx.express-scripts.com for more information.
Are there any other abortion services covered by TRICARE?
TRICARE may cover services or supplies related to spontaneous, missed or threatened abortions or abortions related to ectopic pregnancies. Visit our Benefits A-Z Abortion page and www.tricare.mil/CoveredServices for details.
Is a prior authorization required for abortion services?
Active duty service members must have a prior authorization. A prior authorization is not required for non-active duty beneficiaries; however, HNFS recommends providers submit a prior authorization request so we can do a benefit review. To expedite review, providers may attach an LOA (available at our Letters of Attestation page) instead of clinical documentation to the request.
Who can order abortion services?
Abortion services may be ordered by the beneficiary’s primary care provider or a relevant specialist. Note: Under TRICARE Prime, non-preventive obstetric or gynecologic services require a referral from the beneficiary’s primary care manager (PCM).
Are any other services covered for abortions?
TRICARE covers medical and/or mental health services for covered abortions, including ultrasounds performed prior to the abortion; pathology services; pregnancy tests; office visits; follow-up care for covered abortions, such as psychotherapy; and any applicable requirements mandated by state or local laws.
Can beneficiaries receive covered abortion services in a state other than where they live?
Yes, non-active duty beneficiaries enrolled in TRICARE Prime or TRICARE Prime Remote also may be eligible for travel benefits to receive non-emergent covered services in another state under the TRICARE Prime Travel Benefit. Specific guidelines apply. Prime beneficiaries who seek covered services from non-network providers without HNFS approval are subject to Point-of-Service costs. Beneficiaries enrolled in non-Prime plans may receive covered services in another state; however, non-network cost-shares and deductibles will apply when seeing non-network providers.
What abortion-related services are not covered by TRICARE?
- Abortion-related services and supplies that do not comply with TRICARE requirements
- Mental health and other services for a non-covered abortion (e.g., counseling, referral, preparation, follow-up)
- Abortions for fetal abnormality or for psychological reasons