[Federal Register Volume 89, Number 217 (Friday, November 8, 2024)]
[Notices]
[Pages 88742-88744]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-26066]


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DEPARTMENT OF DEFENSE

Office of the Secretary


TRICARE: Notice of TRICARE Plan Program Changes for Calendar Year 
2025

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

ACTION: Notice; TRICARE Plan Program Changes for Calendar Year 2025.

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SUMMARY: This notice provides information regarding TRICARE Plan 
Program Changes for Calendar Year (CY) 2025.

DATES: TRICARE Health Plan information in this notice is valid for 
services during CY 2025 (January 1, 2025-December 31, 2025).

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

FOR FURTHER INFORMATION CONTACT: Ms. Debra Fisher, phone: (703) 275-
6224.

SUPPLEMENTARY INFORMATION: A final rule published in the Federal 
Register (FR) on February 15, 2019, (84 FR 4326-4333) established the 
requirement for the Director, Defense Health Agency (DHA), to provide 
public notice to Military Health System (MHS) beneficiaries each 
calendar year in connection with the annual open season enrollment 
period with a summary of changes to the TRICARE program. The following 
changes or improvements to the TRICARE program benefits apply for CY 
2025.

Announcement of Open Season

    Open Season is an annual period when beneficiaries can enroll in or 
make changes to their healthcare, dental, and vision coverage for the 
next calendar year.
    During the TRICARE Open Season that runs from November 11, 2024, 
through December 10, 2024, qualified MHS beneficiaries may enroll in or 
change their TRICARE Prime or TRICARE Select plan.
    During the Federal Employee Dental and Vision Insurance Program 
(FEDVIP) Open Season that runs from November 11, 2024, through December 
9, 2024, qualified MHS beneficiaries, including TRICARE for Life 
beneficiaries, may enroll in or make changes to their dental and vision 
plans. FEDVIP is operated by the U.S. Office of Personnel Management.
    Any changes MHS beneficiaries make during Open Season will take 
effect on January 1, 2025. If a beneficiary remains eligible and does 
not make any changes during Open Season, then their coverage will stay 
the same for 2025. TRICARE enrollees can ensure they receive important 
health plan information by promptly listing any change in address and 
other information in the Defense Enrollment Eligibility Reporting 
System (DEERS). See the Qualifying Life Events (https://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLEhttps://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLE) guide for when to 
update information in DEERS throughout the year.

Annual Announcements

    The following TRICARE program features are subject to a year-to-
year determination and are announced each year prior to the annual 
TRICARE Open Season.
    Urgent Care Visits: There continues to be no limit on the number of 
urgent care visits covered beneficiaries enrolled in TRICARE Prime can 
receive without a referral for Plan Year 2025. Beneficiaries may 
receive urgent care from TRICARE-authorized urgent care centers (UCC) 
and convenience clinics (CC), either network or non-network, without a 
referral. They may also receive urgent care from any TRICARE network 
provider (i.e., family medicine; internal medicine-general practice; 
pediatricians). In situations when a TRICARE Prime enrollee seeks care 
from a non-network TRICARE authorized provider (outside of a TRICARE-
authorized UCC or CC), the usual TRICARE Prime Point of Service (POS) 
deductible and cost-shares shall apply. Private Sector care for active 
duty Service members is subject to different rules. Covered 
beneficiaries who want assistance on decisions to seek urgent care in 
the United States (U.S.), except those enrolled in the Uniformed 
Services Family Health Plan (USFHP), may call the MHS Nurse Advice Line

[[Page 88743]]

(NAL) at 1-800-874-2273 for health care guidance from a specially 
trained registered nurse. The NAL is available 24/7 to all non-USFHP 
TRICARE beneficiaries. Beneficiaries who live overseas can call the NAL 
for health care advice when traveling in the U.S. but must coordinate 
care with their Overseas Regional Call Center. For additional 
information, call the servicing TRICARE contractor or visit https://www.tricare.mil/ContactUs and click on ``MHS Nurse Advice Line.''
    Prime Service Area Changes: Prime Service Areas (PSAs) are 
geographic areas around military medical treatment facilities and Base 
Realignment and Closure sites. PSAs support the medical readiness of 
active duty members of the Uniformed Services by adding to the 
capability and capacity of military hospitals and clinics. There are no 
changes to the existing PSAs for calendar year (CY) 2025.

What's New

    The following changes or improvements to the TRICARE program 
benefits apply to CY 2025 (although some changes were implemented in 
2024):

Managed Care Support Contractors

    TRICARE Managed Care Support Contracts for East and West Regions 
Change: Effective January 1, 2025, a set of new TRICARE Managed Care 
Support contracts that facilitate health care in the private sector 
will serve beneficiaries in the East and West regions. Under the new 
contracts, beneficiaries residing in Arkansas, Illinois, Louisiana, 
Oklahoma, Texas, and Wisconsin will shift from the East to the West 
region.

    Note:  Beneficiaries residing in Arkansas, Illinois, Louisiana, 
Oklahoma, Texas, and Wisconsin, and TRICARE Prime and Select 
beneficiaries transitioning from HealthNet Federal Services to 
TriWest must contact their regional contactor if they are paying 
enrollment fees or premiums by recurring credit card and electronic 
funds transfer (EFT) to provide their payment information to ensure 
there is no break in TRICARE health care coverage.

    Beneficiaries in the West Region will have a new contractor 
administering their TRICARE benefit, TriWest Health Alliance. 
Contractor contact information for West Region beneficiaries receiving 
services on or after January 1, 2025, is provided here: TriWest 
Healthcare Alliance, P.O. Box 43470, Phoenix, AZ 85080-3470, Phone: 1-
888-TRIWEST (874-9378); Fax: 1-866-566-9915, www.tricare.mil/West. 
Beneficiaries in the East Region will continue to have their TRICARE 
benefits administered by Humana Government Business.
    The TRICARE East and West contracts include new requirements added 
to allow enrolled beneficiaries to call their regional contractors to 
get help with network appointments. This requirement is intended to 
assist beneficiaries currently enrolled to the network who need support 
for making appointments. Beneficiaries who frequently encounter 
problems with network providers not accepting new patients can contact 
the regional contractor for assistance.

Benefit Changes

    Coverage of Hearing Aids for Child Dependents of Former Members of 
the Uniformed Services: Hearing aids and hearing aid services and 
supplies to address profound hearing loss may be covered for child 
dependents of former members of the Uniformed Services who are enrolled 
in TRICARE Prime, effective December 22, 2023. Hearing aid benefits are 
available to dependents of a member of the Uniformed Services on active 
duty, which includes all members covered under the Transitional 
Assistance Management Program.
    Automatic Blood Pressure Monitors: Automatic blood pressure 
monitors may be covered under TRICARE's Durable Medical Equipment 
policy, when prescribed for a beneficiary who is also receiving covered 
Remote Physiologic Monitoring services, for medically necessary self-
measured blood pressure monitoring, effective June 29, 2023.
    Lipectomy (Liposuction) for Treatment of Lipedema: Medically 
necessary liposuction for the treatment of lipedema may be covered when 
certain coverage criteria are met and with prior authorization, 
effective May 28, 2021.
    TRICARE Coverage for Over-The-Counter (OTC) Norgestrel: The TRICARE 
pharmacy formulary for OTC drugs covers Norgestrel (Opill) tablet with 
a doctor's prescription. TRICARE plan copayments or cost-shares may 
apply. This addition to the TRICARE drug formulary does not change OTC 
coverage of Levonorgestrel (Plan B One-Step Emergency Contraceptive) 
for free without a doctor's prescription. Beneficiaries may see the 
TRICARE drug formulary search tool for further information.

Demonstration Changes and Extensions

    Childbirth and Breastfeeding Support Demonstration (CBSD) 
Childbirth Support Services Adjustments: The CBSD will continue into 
calendar year 2025 and is available to all beneficiaries except those 
enrolled in USFHP, the Continued Health Care Benefit Program, and those 
receiving TRICARE coverage under TRICARE for Life, with the following 
adjustments.
    First, starting January 1, 2025, all Certified Labor Doulas (CLDs) 
performing services under the CBSD must have an agreement to 
participate with TRICARE, which means the CLD must file claims and 
accept TRICARE reimbursement as payment in full. Beneficiaries must 
select a CLD who has agreed to participate (in-network or out-of-
network) to have TRICARE pay for services. No coverage will be provided 
for services received from a CLD without a TRICARE participation 
agreement. Beneficiaries who select a TRICARE-participating CLD will 
have no out-of-pocket expenses (after the annual deductible has been 
met). Second, the allowance for six untimed visits with a CLD either 
before or after delivery are replaced by six hours of visits, which can 
be used in 15-minute increments for visits of different lengths. Third, 
TRICARE raised the reimbursement rates for CLDs. Fourth, the National 
Black Doula Association has been added as an accepted certifying 
organization for CLDs. Finally, TRICARE is waiving the certification 
requirement for CLDs with active Medicaid participation in the state 
where practicing. Phase 1 will end on January 1, 2025, and a new Phase 
2 reimbursement for childbirth support services provided in the 50 
United States and District of Columbia will be effective from January 
1, 2025, through December 31, 2026. For overseas locations, the 
effective date for Phase 2 reimbursement is also January 1, 2025, 
through December 31, 2026.
    CBSD Overseas: Starting January 1, 2025, beneficiaries enrolled to 
the TRICARE Overseas Program (TOP) are eligible for demonstration 
services (doula support and breastfeeding support by authorized 
demonstration providers) when all demonstration requirements are met. 
Unlike in the U.S., TOP beneficiaries must enroll in the CBSD with the 
overseas contractor to be eligible. Beneficiaries can search provider 
directories to locate CBSD providers near them in Germany, Japan, 
Italy, South Korea, Puerto Rico, and the United Kingdom; in other 
countries, the overseas contractor will work with the enrolled 
beneficiary to find a qualified provider, if available.

Preventive Service Changes

    Pre-Exposure Prophylaxis (PrEP) for, for the Prevention of HIV 
Acquisition: Effective January 1, 2025, HIV pre-exposure prophylaxis 
with effective antiretroviral therapy (i.e., Apretude), as

[[Page 88744]]

well as related office visits, for adolescents and adults at increased 
risk of acquiring HIV, when provided to TRICARE Prime patients of by 
network providers to TRICARE Select patients, will be considered 
clinical preventive services not subject to cost-sharing.
    Digital Breast Tomosynthesis for Breast Cancer Screening as a 
Clinical Preventive Services Benefit: DHA will permanently cover 
digital breast tomosynthesis (DBT), also known as 3D mammography, as a 
clinical preventive services benefit not subject to cost-sharing.

Provisional Coverage Changes

    Digital Breast Tomosynthesis for Breast Cancer Screening as a 
Clinical Preventive Services Benefit: Provisional Coverage of DBT for 
breast cancer screening, which spanned from January 1, 2020, to 
December 31, 2024, will lapse. However, as noted above, DHA will 
continue to cover DBT as a clinical preventive services benefit not 
subject to cost-sharing.
    Platelet-Rich Plasma for Major Joint Treatment and Rehabilitation: 
Platelet-rich plasma (PRP) injections are excluded from coverage for 
all indications. The use of PRP for knee osteoarthritis and lateral 
elbow tendinopathy was covered under Provisional Coverage status from 
October 1, 2019, to September 30, 2024. Provisional Coverage of PRP 
lapsed on September 30, 2024, and will not be replaced with permanent 
coverage.

Appendix A

    Certain TRICARE enrollee out-of-pocket costs (enrollment fees, 
premiums, catastrophic caps, deductibles, and copayments) are adjusted 
annually by federal law and regulations based on the annual Cost of 
Living Adjustment (COLA) applied to Uniformed Service member retired 
pay. A difference in copayments remains between those who joined a 
Uniformed Service before January 1, 2018, (Group A), and those who 
joined on or after that date (Group B).
    The retiree COLA is typically announced after the federal fiscal 
year begins in October. Beneficiary out-of-pocket expenses impacted by 
the 2025 COLA will be posted to the tricare.mil/changes web page before 
the start of TRICARE Open Season, November 11, 2024.

Premium Based Plans

    The CY 2025 monthly premiums for TRICARE Reserve Select, TRICARE 
Retired Reserve, and TRICARE Young Adult and the quarterly premiums for 
Continued Health Care Benefit Program will be posted to the 
tricare.mil/changes web page once announced.

Pharmacy Out-of-Pocket Expenses for CY 2025

    TRICARE Pharmacy copayments will remain unchanged on January 1, 
2025:

                                                      Pharmacy Copayments For Calendar Year 2025 *
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                                                        Retail network
                                    Retail network        brand-name      Retail network non- Mail order generic   Mail order brand-    Mail order Non-
              Year                 generic formulary   formulary 30-day    formulary 30-day    formulary 90-day   name formulary 90-   formulary 90-day
                                     30-day supply          supply              supply              supply            day supply            supply
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2025............................                $16                 $43              $76 **                 $13                 $38                 $76
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* Active-duty Service members (ADSM) enjoy a $0 copay for covered drugs at any pharmacy.
** For all beneficiaries except ADSM, select brand-name maintenance medications (taken for long-term conditions) may only be filled twice at retail and
  then must be filled through home delivery or military pharmacy.


    Dated: November 5, 2024.
Stephanie J. Bost,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2024-26066 Filed 11-7-24; 8:45 am]
BILLING CODE 6001-FR-P