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TRICARE; Notice of TRICARE Plan Program Changes for Calendar Year 2021

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Office of the Secretary of Defense, Department of Defense (DoD).




This notice provides a notification of TRICARE Plan program changes for calendar year 2021. Changes or improvements to the TRICARE program benefits are provided in the supplementary information section.


TRICARE health plan information in this notice is valid for services during calendar year 2021 (January 1, 2021-December 31, 2021).


Defense Health Agency, TRICARE Health Plan, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.

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Mr. Mark A. Ellis, (703) 681-0039.

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An interim final rule published in the Federal Register (FR) on September 29, 2017 (82 FR 45438-45461) established the requirement for the Director, Defense Health Agency, to provide a public notice to TRICARE program beneficiaries with a summary of changes to the TRICARE program each calendar year in connection with the open season enrollment period.Start Printed Page 68313

The following changes or improvements to the TRICARE program benefits apply for calendar year 2021:

  • Improving what's covered:

Coronavirus Disease 2019 (COVID-19) Response:

➢ The following three temporary changes were made effective May 12, 2020, for care and treatment within the United States (US) and effective March 10, 2020, for the TRICARE Overseas Program: Temporary audio-only telephonic office visits; temporary waiver of cost-shares, co-pays and deductibles for all covered in-network telehealth services (for Prime and Select beneficiaries); and temporary interstate and international licensing. These changes will expire when the President of the US declares the national emergency is terminated. Overseas termination date may vary from the US date and will be determined by the Assistant Secretary of Defense for Health Affairs.

➢ Flexibility was added for reinstatement of coverage for TRICARE Reserve Select (TRS) by expanding the three-month window to reinstate coverage for a beneficiary due to a lapse in coverage to a five-month window. This is in effect until the termination of the state of national emergency.


➢ Effective January 1, 2020, Digital Breast Tomosynthesis (DBT) for Breast Cancer (BC) Screening is covered under the Provisional Coverage Program. This three-dimensional mammography DBT for BC screening may be covered annually instead of conventional two-dimensional screening mammography. It is covered for all women beginning at age 40 and covered annually beginning at age 30 for women who have a 15 percent or greater lifetime risk of breast cancer. No pre-authorization is required.

➢ Effective December 2, 2019, and covered under the TRICARE Basic Program, this change allows for the separate reimbursement of instrument-based vision screening for children age one to age six when provided by a physician other than an ophthalmologist or optometrist as part of a regular preventive office visit under the well-child care program. No pre-authorization is required.

Mental Health:

➢ The Autism Care Demonstration is focused on ensuring TRICARE beneficiaries diagnosed with autism spectrum disorder (ASD) and their families receive high-value care and services that will help them reach their maximum potential. During the COVID-19 period, DHA has authorized the temporary use of unlimited applied behavior analysis parent/training guidance (Current Procedural Terminology Code 97156) only via telehealth to ensure Military children diagnosed with ASD and their families continue to receive support during the crisis. This exception to policy allows parents to maintain elements of the treatment plan during the crisis, which has in many cases made provision of in- person services impossible or unsafe.

➢ Effective March 5, 2019, but implemented in 2020, SpravatoTM is covered under the Basic Medical Program for treatment-resistant depression. This drug is administered intra-nasally under the supervision of a TRICARE-authorized provider during an office visit. Pre-authorization under the medical benefit is required. Off-label use of Spravato is excluded.

Demonstrations, Programs & Pilots:

➢ The existing Laboratory Developed Test (LDT) demonstration ensuring beneficiaries continue to have access to safe and effective non-FDA approved LDTs has been extended for an additional three years. Additionally, TRICARE Overseas Program (TOP) beneficiaries may now receive tests covered under the LDT demonstration from either Clinical Laboratory Improvement Amendments of 1988-certified laboratories or laboratories otherwise approved by the TOP contractor in conjunction with specific government-directed standards.

➢ Effective January 1, 2020, TRICARE implemented a three-year Home Health Value-Based Purchasing demonstration designed to improve the quality and delivery of home health services by rewarding providers with incentive payments that give higher quality and more efficient care. This demonstration applies to home health agencies that provide services in the following nine states: Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington.

➢ Launched on May 1, 2020, the TRICARE Select Navigator Program provides a health care assistance service to certain covered beneficiaries enrolled in TRICARE Select using purchased care to improve health outcomes and patient experience for covered beneficiaries with complex medical conditions.

➢ Humana Military continues to partner with Kaiser Permanente to offer care and coverage to TRICARE Prime eligible beneficiaries in the Atlanta, Georgia area through the TRICARE Accountable Care Pilot. The pilot began on January 1, 2020, and will continue through 2022.

Other Significant Changes:

➢ Effective January 1, 2020, and covered under the TRICARE Basic Medical Program, Continuous Glucose Monitor Systems (CGMS) are now covered for Type 2 diabetes in addition to Type 1 diabetes. Smart phones and watches used in conjunction with CGMS are not covered.

➢ Effective November 21, 2019, and covered under the TRICARE Basic Medical Program, this benefit enhancement adds coverage for non- implantable bone conducting hearing devices for infants and toddlers who are too young (typically age 5 and younger) for implants. These devices are considered a prosthetic bridge to transplantation for patient whose skull development will not yet support an implant, and are also covered as prosthetic devices for Active Duty Family Members who meet criteria for hearing aid coverage. No preauthorization is required.

➢ Effective April 16, 2020, TRICARE reimburses for care provided by Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs) who are supervised by physical therapists and occupational therapists, increasing the provider pool available to care for TRICARE beneficiaries.

➢ A Move Away From Lower-Value-Care Interventions: (1) Vitamin D Screening for otherwise healthy/asymptomatic individuals is excluded as the screening has no impact on health outcomes. (2) Transcutaneous Electrical Nerve Stimulators are excluded for acute, subacute and chronic low back pain because there is increasing evidence that this treatment is not effective.

  • Out-of-Pocket Costs:

Certain beneficiary out-of-pocket costs (enrollment fees, premiums, catastrophic caps, deductibles, and copayments) are annually adjusted based on federal law and regulations, most notably by the annual retiree cost of living adjustment, or Cost of Living Adjustment (COLA). Currently there is a difference in copayments between those who joined the military before January 1, 2018, (Group A), and those who joined after that date (Group B). The retiree COLA will not be announced until mid-October 2020. As of August 31, 2020, the projected COLA increase is 1.3 percent. Beneficiary out-of-pocket expenses impacted by the 2020 COLA will be posted to the web page before the start of TRICARE Open Season.

Pharmacy Out-of-Pocket Expenses for CY 2021 remain the same. See table below for TRICARE Pharmacy out-of-pocket expenses that take effect on January 1, 2021.Start Printed Page 68314

Table 1—Pharmacy Copayments for Calendar Year 2021

YearCopayment amount for a 30-day supply of a retail generic is:Copayment amount for a 30-day supply of a retail formulary is:Copayment amount for a 90-day supply of a mail order generic is:Copayment amount for a 90-day supply of a mail order formulary is:Copayment amount for a 90-day supply of a mail order non-formulary is:
  • For more information, visit or call your regional TRICARE contractor.
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Dated: October 22, 2020.

Aaron T. Siegel,

Alternate OSD Federal Register Liaison Officer, Department of Defense.

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[FR Doc. 2020-23892 Filed 10-27-20; 8:45 am]