Following the United States 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. Humana Military offers the following refresher on TRICARE’s coverage guidelines for abortion services.
Abortion is covered by TRICARE when a pregnancy results from acts of rape or incest, or the life of the mother is at risk. Important: The attending healthcare provider must document in the beneficiary’s medical record that an abortion was performed for one of the above criteria. The quickest, easiest way to request a new referral or authorization or update an existing referral or authorization is through provider self-service.
Oral medications used to end a pregnancy are a TRICARE-covered service when a pregnancy is caused by an act of rape or incest. Coverage of Mifeprex and all associated services and supplies are only provided 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 Militaryrx.express-scripts.com for more information.
TRICARE may cover services or supplies related to spontaneous, missed or threatened abortions or abortions related to ectopic pregnancies. Visit TRICARE.mil/CoveredServices for details.
Active Duty Service Members (ADSM) must have a prior authorization. A prior authorization is not required for non-active duty beneficiaries; however, Humana Military recommends providers submit a prior authorization request for a benefit review. The quickest, easiest way to request a new referral or authorization or update an existing referral or authorization is through provider self-service.
Abortion services must be ordered by the beneficiary’s Primary Care Manager (PCM) or a relevant specialist. Note: Under TRICARE Prime, non-preventive obstetric or gynecologic services require a referral from the beneficiary’s PCM.
TRICARE covers medical, behavioral/mental health services or both for covered abortions.
Non-active duty beneficiaries enrolled in TRICARE Prime or TRICARE Prime Remote (TPR) may be eligible 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 Humana Military approval are subject to Point-Of-Service (POS) 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.