TRICARE Well-Child Coverage Overview
The preventive care and check-ups you as a health care professional provide from birth to age 6 can influence a child’s health
for the rest of his or her life. TRICARE covers well-child care in accordance with American Academy of Pediatrics (AAP) and Centers
for Disease Control and Prevention (CDC) guidelines.
Well-child care is covered by TRICARE as clinical preventive care. The following is an overview:
In-hospital Newborn Care
- Circumcision – if performed after the child has been discharged from the hospital, the service is cost-shared as an outpatient
service (unless it qualifies for the special cost-sharing for ambulatory surgery and the procedure is done at a hospital or free-standing
ambulatory surgery center). Refer to a recent E-Newsletter article
on circumcision for more information.
- AAP-recommended newborn screenings, including, but not limited to:
- Hypothyroidism
- Phenylketonuria
- Hemoglobinopathies (for those in high-risk ethnic groups)
- Galactosemia
The Department of Defense closely monitors AAP recommendations in regards to newborn metabolic screening. The AAP has endorsed a report
recommending expanded metabolic screening for newborns. Additional information about the report can be found at
http://mchb.hrsa.gov/screening/summary.htm and
http://genes-r-us.uthscsa.edu.
Well-child Office Visits
Provide preventive care well-child visits as frequently as the AAP recommends, but no more than nine visits in two years. Visits for
diagnosis or treatment of an illness or injury are covered separately under outpatient care.
The following chart shows TRICARE-covered tests and their AAP-recommended recommended frequency.
| Test |
Frequency |
| History/physical examination/mental health assessment |
Each well-child visit |
| Height and Weight |
Each well-child visit |
| Head Circumference |
Each well-child visit through age 2 |
| Vision Screening (by PCM) |
At birth and at well-child visit at age 6 months |
| Comprehensive Eye Exam (by Optometrist or Ophthalmologist) |
Available from birth to age six; includes eye and vision screening by a primary care manager (PCM) during
a routine exam at birth and at approximately six months of age |
| Dental Screening |
Each well-child visit |
| Tuberculin Test |
Once at age 1; once at age 2 |
| Hemoglobin or Hematocrit Testing |
Once during first year; once during second year |
| Urinalysis |
Once during first year; once during second year |
| Blood Pressure Screening |
Annually between age 3 and 6 |
Immunizations
TRICARE covers age-appropriate doses of vaccines recommended by the CDC’s Advisory Committee on Immunization Practices. For
a current schedule, refer to www.cdc.gov.
Other Tests (special criteria)
- Audiology screening (in hospital or before age 3 months only for high-risk neonates as defined by the Joint Committee
on Infant Hearing)
- Blood lead test – A blood lead test (CPT code 83655) during each well-child visit from age six months to less than 6 years
of age is covered by TRICARE if the assessment of risk for lead exposure is positive based on a structured questionnaire developed
by the Centers for Disease Control and Prevention (CDC). For more information, please refer to an article on lead testing.
- Flu shot – All children age 6-23 months. Refer to a recent E-Newsletter
article on flu shots.
- School physicals: For children ages 5 through 11 who require physicals in connection with the enrollment as a student in that school.
This benefit does not include physical exams that may be required by the school solely to participate in school sports. Refer to a
recent article on school physicals.
Other clinical preventive examinations or comprehensive health promotion and disease prevention exams are available for ages 24 months
and older under the Clinical Preventive Services benefit.
For more information, refer to the TRICARE Web site at
www.tricare.mil or call
TriWest at 1-888-TRIWEST (888-874-9378).
