February 12, 2020
Area(s) of Interest: Payor Issues and Reimbursement
As of January 1, 2020, TRICARE now covers annual 3-D mammography screenings through its provisional coverage program. Previously, TRICARE only covered 3-D mammograms for diagnostic purposes. As a provisional benefit, prior authorization for 3-D mammography is required regardless of TRICARE plan type.
As with 2-D screening mammograms, 3-D screening mammograms are covered for women who are:
- Age 40 or older, or
- Age 30 or older and at high risk (a Letter of Attestation can be submitted in lieu of clinical documentation for this category)
High-risk indicators include:
- A lifetime risk of breast cancer of 15% or greater using standard risk assessment models, such as Gail model, Claus model or Tyrer-Cuzick
- History of breast cancer
- Known BRCA1 and BRCA2 gene mutation
- A parent, child or sibling with a BRCA1 or BRCA2 gene mutation and the beneficiary has not had genetic testing for this mutation
- Radiation therapy to the chest between 10 and 30 years of age
- History of LiFraumeni, Cowden or Bannayan-Riley-Ruvalcaba syndrome, or a parent, child or sibling with a history of one of these syndromes
For additional benefit details, please visit the TRICARE West website under the Benefits A–Z page.