Download ISSUE FB 11-11: TRICARE Coverage for Contact Lenses

ISSUE FB 11-11:
TRICARE Coverage for Contact Lenses
Issue: Why is it that TRICARE will pay for an eyeglass examination
and a pair of glasses, but not for contacts? If someone only chooses
to wear contacts and not glasses, I don’t see why TRICARE cannot pay
for the contacts. I can understand that they won’t pay for both
glasses and contacts. I don’t understand why they won’t pay for a
contacts examination it’s still checking out the eyes. This is my
understanding and I go to a TRICARE approved eye doctor.
Solution: Please see if it’s possible for TRICARE to pay for contacts
and the contacts eye examination. I think that Family members should
be able to choose what type of corrective eyewear that they prefer one
or the other, not just the option of eye glasses.
MCXC-PRD
1 October 2011
INFORMATION PAPER
SUBJECT: FB Issue 11-11:
TRICARE Coverage for Contact Lenses
1. PURPOSE:
To provide information on subject issue to the Fort
Bragg Family Action Plan Conference.
2. ISSUE: Why is it that TRICARE will pay for an eyeglass
examination and a pair of glasses, but not for contacts? If someone
only chooses to wear contacts and not glasses, I don’t see why TRICARE
cannot pay for the contacts. I can understand that they won’t pay for
both glasses and contacts. I don’t understand why they won’t pay for
a contacts examination it’s still checking out the eyes. This is my
understanding and I go to a TRICARE approved eye doctor.
3. SOLUTION: Please see if it’s possible for TRICARE to pay for
contacts and the contacts eye examination. I think that Family
members should be able to choose what type of corrective eyewear that
they prefer one or the other, not just the option of eye glasses.
4.
RECOMMENDATION:
No change.
Response:
Since contact lenses are generally considered a “cosmetic service”
contact lenses traditionally have not been a covered benefit under
TRICARE. Additionally, under TRICARE, the supply of non-military
glasses is not a covered benefit for any beneficiary, unless there is
medically justified need.
In general, contact lens fittings and services can generate multiple
visits and there are higher risks associated with that modality of
vision correction. From a clinical perspective, it is the standard of
care to have glasses as a back-up, even if a patient is a contact lens
wearer, just in case they experience a medical condition or develop a
complication with the contacts.
Active Duty military are authorized military eyewear from the MTF in
order to be vision and combat ready for deployment, at no expense to
the Soldier. Retired Service Members are eligible for one pair of
military issue eyewear a year at no cost. Those must be ordered at
the MTF with a valid written non-expired prescription (less than one
year from time of exam).
Cosmetic contact lens service within the MTF Optometry Clinics are
provided on a limited basis to beneficiaries, based on the patient’s
history and health status, current contact lens fit/experience,
availability of trial lenses within the clinic, the provider’s
appointment schedule access and the demand on access to care for
wellness visits for comprehensive exams for spectacles for Active
Duty. These are justified to support maintenance of optometrists’
skills, provide cases for Graduate Medical Education, or to problem
solve existing problems from outside fits.
TRICARE does cover a comprehensive eye exam with the release of a
spectacle prescription for glasses based on the following guidance:
Coverage for eye exams is dependent on who you are and which plan you
are using.

Generally, TRICARE covers:
Annual routine eye exams for active duty service members and active
duty family members
Comprehensive eye exams every two years for beneficiaries enrolled
in TRICARE Prime
Comprehensive eye exam every year for diabetic patients enrolled in
TRICARE Prime. Vision exams under the well-child care benefit.
Ophthalmological services, which may include an eye exam and other
specialized services, are covered in connection with the medical or
surgical treatment of a covered illness or injury
One routine eye examination by an ophthalmologist or optometrist
every 2 years beginning at age 3. These routine eye exams offered
between age 3 and 6 should include screening for amblyopia and
strabismus




Additionally, if there is medically indicated reason for a contact
lens fit, then that can also be covered under TRICARE to include the
contact lens material. (Keratoconus, corneal trauma and other corneal
diseases.)
TRICARE covers contact lenses and/or eyeglasses only for treatment of:






Infantile glaucoma
Corneal or scleral lenses for treatment of keratoconus
Scleral lenses to retain moisture when normal tearing is not
present or is inadequate
Corneal or scleral lenses to reduce corneal irregularities other
than astigmatism
Intraocular lenses, contact lenses, or eyeglasses for loss of
human lens function resulting from intraocular surgery, ocular
injury or congenital absence
"Pinhole" glasses prescribed for use after surgery for detached
retina
Note: Adjustments, cleaning, and repairs for eyeglasses are not
covered.
REFERENCE:
http://www.tricare.mil/mybenefit/jsp/Medical/IsItCovered.do?&kw=Eye%20
Exams&topic=Children
5.
STAFF POSITION:
This issue cannot be resolved at the local level.
Carol Z. Rymer, OD, MBA, FAAO
COL, MS
Chief, Optometry Services - Fort Bragg
Department of Family Medicine
Womack Army Medical Center
Office: 910-907-8574
2011 Fort Bragg Army Family Action Plan (AFAP) Conference
Local Level Issue Staff Position Paper
AFAP Issue:
FB 11-11:
TRICARE Coverage for Contact Lenses
ISSUE: Why is it that TRICARE will pay for an eyeglass examination
and a pair of glasses, but not for contact? If someone only chooses
to wear contacts and not glasses, I don’t see why TRICARE cannot pay
for the contacts. I can understand that they won’t pay for both
glasses and contacts. I don’t understand why they won’t pay for a
contacts examination it’s still checking out the eyes. This is my
understanding and I go to a TRICARE approved eye doctor.
RECOMMENDATION: Please see if it’s possible for TRICARE
contacts and the contacts eye examination. I think that
members should be able to choose what type of corrective
they prefer one or the other, not just the option of eye
to pay for
Family
eyewear that
glasses.
STAFF DISCUSSION:
a. Facts: (Information related to the issue and recommendation
that provides supporting data that addresses the issue (statutes,
regulations, policies or research to include any internal or external
studies).
b. How many affected: (Identify the demographic (i.e., AR, RC,
Soldiers, DA Civilian, Families; and estimated number affected by the
issue).
c. How often and/or when issue occurs: (When is the issue
likely to occur and under what circumstances (during deployment,
during PCS, following an injury).
d. Cost Benefit Analysis: (Estimated cost to accomplish the
issue recommendation that generate new or recurring funding
requirements or savings. Explain how cost was determined. Is the
cost discretionary?)
Staff Recommendation:
a. Merit of the Issue: (Action Officer analysis of how the
issue recommendation will solve the issue. What causes this to be a
problem (i.e., gap, inequality, policy). Why does the current law or
policy not work?)
b. Proposed Solution:
action to solve the issue.)
(Action Officer’s recommended course of
c. Elevation Justification:
resolved at the local level.)
(Explain why the issue cannot be
d. Pros: (How does this issue align with Strategic Goals and
Vision of DoD and the Army (readiness, force management, or other
military concerns. Clearly define expected return on the Army’s
investment (i.e., percentage retained, funding saved, Manpower Usage,
etc.)
e.
issue.)
Cons:
(Potential negative consequences of implementing the
2011 FORT BRAGG AFAP CONFERENCE
Issue Disposition Paper
Work Group: Medical and Dental
Issue Number: FB 11-11
Issue Title: TRICARE Coverage for Contact Lenses
Subject Matter Expert: Robin Talley
Did the workgroup prioritize this issue as a critical
issue?
Yes
No
Issue’s New Title (If prioritized and written by your workgroup)
Were similar issues (same concern) submitted to this AFAP
Conference?
Yes
No
Identify issue number and title of similar issue:
Issue Number:
Issue Title:
Issue clarity
Was the issue clearly written?
Yes
No
Did Delegates understand this issue?
Yes
No
If not, what was the problem in fully understanding it?
DISPOSITION: Glasses are a necessity but contacts are a nice to have. SME stated if contacts are a
medical necessity they will be covered.
Identify the primary reason(s) the work group did not prioritize this issue. Please be specific—these
comments are returned to the submitting Command.
Check here if issue was prioritized by the workgroup.