Examining the TRICARE Vision Benefit

Routine Eye Exam

• Evaluation of the eyes (including, but not limited to, refractive services) that is not related to a medical or surgical condition or to the medical or surgical treatment of a covered illness or injury
• Covered annually for ADSMs and ADFMs at no cost
• A PCM referral or TriWest authorization is not required for TRICARE Prime beneficiaries in most cases, unless care is received from a non-network provider
• ADSMs always require a referral

Clinical Preventive (Comprehensive) Eye Exam

• Comprehensive screening for determination of vision or visual acuity, ocular alignment and red reflux, along with external exam for ocular abnormalities
• Covered every two years for all TRICARE Prime enrollees with no co-pay
• Primary Care manager referral or authorization from TriWest is not required for TRICARE Prime beneficiaries in most cases, unless care is received from a non-network provider
• ADSMs always require a referral

Routine Vision Benefit

• Routine eye exams are covered annually for ADSMs at no cost.
• ADSMs always require a referral.
• The frequency of routine eye exams is tracked on an annual basis. For example, if an ADSM received an exam on April 1, 2007, the next exam can be scheduled on or after April 1, 2008.

Routine Vision Benefit

• Not applicable – all ADSMs are TRICARE Prime or TRICARE Prime Remote

Routine Vision Benefit

• Eligible for one routine eye exam per calendar year with no copay
• TRICARE Prime beneficiaries need a referral if seeing a non-network provider to avoid Point Of Service additional out-of-pocket expenses The frequency of routine eye exams is tracked on an annual basis. For example, if an ADFM received an exam on April 1, 2007, the next exam can be scheduled on or after April 1, 2008.

Comprehensive Eye Exam

• TRICARE Prime enrollees age three and older are authorized for comprehensive eye exams once every two years.*
• The well-child benefit is available from birth to age six and includes eye and vision screening by a primary care manager (PCM) during a routine examination at birth and at approximately six months of age.
• With the exception of ADSMs, TRICARE Prime enrollees may receive services from any TRICARE network provider without a referral or authorization from their PCM or TriWest. There is no copay when utilizing a network provider. If the comprehensive eye exam is not available from a network provider, enrollees may only receive services from a non-network provider if they have a referral from the PCM and authorization from TriWest. If authorized services are received from a non-network provider, point-of-service fees will NOT apply and there is no copay. If a beneficiary receives services from a non-network provider that has NOT been authorized by TriWest; the beneficiary will be responsible for the point of service deductible and cost share.
• Diabetic patients, at any age, are allowed annual comprehensive eye exams.

Lenses (lenses implanted within the eye or contacts) and Eye Glasses

ADSMs should get their contacts or eye glasses from the MTF. ADSMs need prior authorization for eyeglasses or contact lenses if they get them from a civilian provider.

Except for active duty service members, lenses or eye glasses are only cost shared for treatment of the following conditions:

• Infantile glaucoma
• Keratoconus
• Dry eyes
• Irregularities in the shape of the eye
• Loss of human lens function resulting from eye surgery or congenital absence

Benefits are limited to only one set of implantable lenses required to restore vision. A set may include a combination of both implantable lenses and eyeglasses when the combination is necessary to restore vision. If there is a prescription change related to the qualifying eye condition, a new set may be cost shared.

Replacement lenses for those that are lost, have deteriorated, or have become unusable due to physical growth are not covered. Adjustments, cleaning and repairs of eyeglasses are also not covered.

Routine Vision Benefit

• Same as TRICARE Prime ADFMs with the exception that no referral is required

Comprehensive Eye Exam

• Same as TRICARE Prime for beneficiaries age 6 and younger
• TRICARE Standard beneficiaries over age 6 do not have vision coverage.

Lenses (lenses implanted within the eye or contacts) and Eye Glasses

• Same as TRICARE Prime

• Benefits are the same as for TRICARE Prime ADFM, but the frequency is every 2 years for retiree and dependent vision screenings

• Retirees and their family members who use TRICARE Standard, TRICARE Extra and TRICARE For Life are not eligible for routine or comprehensive eye exams. However, eye exams related to a medical condition (e.g., diabetes) are covered.