PWS Attachment 25 MOD15 Tab-A Amplification of the Minimal Stds of Fitness for Deployment CENTCOM AOR.pdf

MOD15-TAB A: AMPLIFICATION OF THE MINIMAL STANDARDS OF FITNESS FOR

DEPLOYMENT TO THE CENTCOM AOR; TO ACCOMPANY MOD FIFTEEN TO

USCENTCOM INDIVIDUAL PROTECTION AND INDIVIDUAL/UNIT DEPLOYMENT

POLICY

1. General. This TAB A accompanies MOD FIFTEEN, Section 15.C. and provides amplification of the minimal standards of fitness for deployment to the CENTCOM area of responsibility (AOR). Individuals possessing a disqualifying medical condition must obtain an exception to policy in the form of a medical waiver prior to being medically cleared for deployment. The list of deployment-limiting conditions is not comprehensive; there are many other conditions that may result in denial of medical clearance for deployment based upon the totality of individual medical conditions and the medical capabilities present at that individual’s deployed location. “Medical conditions” as used here also include those health conditions usually referred to as dental and behavioral health.

A. Uniformed Service Members must meet Service standards of fitness according to Service regulations and policies, in addition to the guidance in the parent MOD 15. See MOD

FIFTEEN REF E, F, G, H, I, JJ.

B. DoD civilian personnel with disqualifying medical conditions could still possibly deploy based upon an individualized medical assessment and approved medical waiver from the appropriate CENTCOM waiver authority. All personnel must be able to perform the duties of their position.

C. DoD Contract personnel will be evaluated for fitness according to MOD FIFTEEN and DoDI

3020.41 (REF J).

D. The final authority of who may deploy to the CENTCOM AOR rests with the CENTCOM

Surgeon and/or the Service Component Surgeons’ waiver authority, not the individual’s medical evaluating entity, deploying platform, or Commander.

E. Regardless of underlying diagnosis, waivers for disqualifying medical conditions will be considered only if all the following general conditions are met:

1. Age less than 65 years for duration of deployment.

2. The condition is not of such a nature or duration that an unexpected worsening or physical trauma is likely to have a grave medical outcome or negative impact on mission execution.

3. The condition is stable and reasonably anticipated not to worsen during the deployment in light of the physical, physiological, psychological, and nutritional effects of assigned duties and location.

4. The condition does not require frequent clinical visits (more than quarterly), ancillary tests, or significant physical limitations, and does not constitute an increased risk of illness, injury, or infection.

5. There is no anticipated need for routine evacuation out of theater for continuing diagnostics or evaluations.

6. Any required, ongoing health care or medications anticipated to be needed for the duration of the deployment are available to the applicant in theater within the Military

Health System or equivalent. Medication must have no special handling, storage, or other requirements (e.g., refrigeration, cold chain, or electrical power requirements).

Medication must be well tolerated within harsh environmental conditions (e.g. heat or cold stress, sunlight) and should not cause significant side effects in the setting of moderate dehydration.

7. Individuals must be able to perform all essential functions of their position in the deployed environment, with or without reasonable accommodation, without causing undue hardship. In evaluating undue hardship, the nature of the accommodation and workplace environment must be considered. Further, the member’s medical condition must not pose a significant risk of substantial harm to the member or others taking into account the condition of the relevant deployed environment, with particular consideration of areas of armed conflict in the AOR. See REF I.

8. The medical condition does not prevent the wear of personal protective equipment, including protective mask, ballistic helmet, body armor, and chemical/biological protective garments.

9. The medical condition does not prohibit required theater immunizations or medications.

10. The medical condition is not anticipated to significantly impair duty performance during the duration of the deployment.

11. The diagnosis, management, and/or treatment of medical conditions does not place an unreasonable burden on deployed medical assets, operational assets, or complicate the evaluation of other reasonably-anticipated illnesses or injuries.

2. Evaluating providers must consider that in addition to the individual’s assigned duties, severe environmental conditions, extremes of temperature, high physiologic demands (water, mineral, salt, and heat management), poor air quality (especially particulates), limited dietary options, sleep deprivation/disruption, and emotional stress may all impact the individual’s health. If maintaining an individual’s health requires avoidance of these extremes or conditions, they should not deploy.

3. Evaluation of functional capacity to determine fitness in conditions of physiologic demand is encouraged for conditions which may impair normal functionality. The evaluating provider should pay special attention to any conditions which may present a hazard to the individual or others and/or preclude performing functional requirements in the deployed setting. Also, the type, amount, suitability, and availability of medications in the theater environment must be considered as potential limitations. Pre-deployment processing centers may vary in medical examination/screening procedures; individuals should contact their respective mobilization site for availability of a processing checklist.

4. The guidance in this document should not be construed as authorizing use of defense health program or military health system resources for health evaluations unless otherwise authorized. Generally, Defense Health Agency and Military Health System resources are not authorized for the purpose of pre-deployment or travel medicine evaluations for contractor employees IAW REF J. Local command, legal, contracting and resource management authorities should be consulted for questions on this matter.

5. Shipboard operations which are not anticipated to involve operations ashore are exempt from the deployment-limiting medical conditions listed below and will generally follow Service specific guidance.

However, sovereign laws of some nations within the CENTCOM AOR may prohibit entry of individuals with certain medical conditions. Contingency plans for emergency evacuation of individuals with diagnoses that could result in or complicate medical care in theater following evacuation should be coordinated with and approved by the CENTCOM Surgeon prior to entering the AOR.

6. Per general guidance from MOD FIFTEEN, section 15.C:

A. All personnel (uniformed service members, government civilian employees, volunteers, and DoD contractor employees) deploying to theater must meet medical, dental, and behavioral health fitness standards for deployment and possess a current Periodic Health Assessment (PHA) or physical. Fitness specifically includes the ability to accomplish tasks and duties unique to a particular operation and the ability to tolerate environmental and operational conditions of the deployed location.

B. The existence of a chronic medical condition may not necessarily require a waiver to deploy.

Personnel with existing conditions, other than those outlined in this document, may deploy if either:

1. An approved medical waiver, IAW Section 15.C.3, is documented in the medical record.

OR

2. The conditions in Para. 1.D.1-1.D.10 are met. To determine stability and assess need for further care, for most conditions 60 days is considered a reasonable timeframe, subject to the examining provider’s judgment. The exception to this is noted in paragraph 7.G. Behavioral health Conditions.

7. Documented medical conditions precluding medical clearance. A list of all possible diagnoses and their severity that may cause an individual to be non-deployable would be too expansive. The medical evaluator must carefully consider whether the climate, altitude, nature of available food and housing, availability of medical, behavioral health, dental, surgical, and laboratory services, or whether other environmental and operational factors may be hazardous to the deploying person’s health. The following list of conditions should not be considered exhaustive. Other conditions may render an individual medically non-deployable (see paragraph 6). Medical clearance to deploy with any of the following documented medical conditions may be granted, except where otherwise noted, IAW MOD FIFTEEN, Section 15.C. If an individual is found deployed with a pre-existing non-deployable condition and without a waiver for that condition, a waiver request to remain deployed should be submitted to the respective Component Surgeon. If the waiver request is denied, the individual will be redeployed out of the CENTCOM AOR. Individuals with the following conditions and/or therapeutic interventions will not deploy without an approved waiver:

A. Specific Medical Conditions / Restrictions:

1. Asthma or other respiratory conditions that have a Forced Expiratory Volume-1 < 50% of predicted, that have required hospitalization or emergency room visit in the past 12 months, or that require daily systemic (not inhaled) steroids. Mild intermittent asthma does not require waiver.

2. Seizure disorder, either within the last year or currently on anticonvulsant medication for prior seizure disorder/activity. Persons on a stable anticonvulsant regimen, who have been seizure-free for one year, may be considered for waiver.

3. Diabetes mellitus, type 1 or 2, on pharmacotherapy or with HgA1C > 7.0.

a. Type 1 diabetes or insulin-requiring type 2 diabetes.

b. Type 2 diabetes, on oral agents only, with no change in medication within the last 60 days and HgA1C ≤ 7.0 does not require a waiver if a calculated 10-year coronary heart disease risk percentage (see paragraph 7.B.7) is less than 15%.

If the calculated 10-year risk is 15% or greater, further evaluation is required prior to waiver submission. See 7.B.7.

c. Newly diagnosed diabetics will require demonstrated stability, either on oral medications or with lifestyle changes, before a waiver will be considered.

Confirmation of complete initial diabetic evaluation (eye exam, foot exam, nutrition counseling, etc.) is required.

4. History of heat stroke or rhabdomyolysis. Those without multiple episodes, persistent sequelae or organ damage, or episodes within the preceding 24 months may be considered for waiver. Waiver should include circumstances of the event(s), and functional assessment of current ability to perform rigorous duties in an environment similar to the deployed location.

5. Meniere’s disease or other vertiginous/motion sickness disorder, unless well controlled on medications available in theater.

6. Recurrent syncope for any reason. Waiver request should include the etiology and diagnosis of the condition.

7. History of stinging insect allergy causing generalized symptoms, IAW Ref JJ.

a. Local swelling, itching, or redness contiguous with the sting site and exhibiting no signs of anaphylaxis or systemic reaction do not require waiver. Generalized cutaneous-only reactions that occurred prior to the 16th birthday also do not require waiver.

b. Severe systemic and anaphylactic reactions, as well as cutaneous reactions – defined as generalized rash or swelling in locations not contiguous with sting site

- occurring after the 16th birthday, should be referred to an allergist for testing.

c. Negative testing results indicate no further therapeutic action is required, however a waiver should still be submitted for review.

8. Endocrine conditions that are unstable, require laboratory monitoring or specialty consultation, or require more than routine follow-up. Waiver is not required if condition is stable, treatment medications are within clinically appropriate dose and effect parameters, have no special storage requirements, and do not produce side effects which interfere with the normal performance of duties or require additional medications to manage side effects. If treatment consists of CSA schedule I-V medication a waiver for that medication is required, see section I, 8 below.

9. Any musculoskeletal condition that significantly impairs performance of duties or activities of daily living in a deployed environment. If there are concerns, an official functional capacity exam (FCE) should be performed and results included with the waiver request.

10. Migraine headache, when frequent or severe enough to disrupt normal performance of duties. Waiver submission should note history, frequency, severity, and functional impact of headaches, with or without treatment, success of abortive therapies, as well previous and current treatment regimens. Neurology evaluation and endorsement encouraged.

11. Nephrolithiasis, requiring clinical evaluation or intervention in the preceding 12 months, or with most recent imaging showing multiple stones or a single stone >5mm in size, or a history of more than two episodes in a 12 month period in the last 3 years.

12. Pregnancy.

13. Obstructive sleep apnea (OSA). Should be diagnosed with polysomnography (PSG), with a minimum of 2 hours of total sleep time. Individuals previously diagnosed with OSA do not require updated or repeat PSG unless clinically indicated (i.e. significant change in body habitus, corrective surgery or return of OSA symptoms). The condition must not be severe enough to pose a safety risk should PAP therapy be unavailable for a significant length of time. For moderate and severe OSA, a compliance report demonstrating at least 4 hours of use per night for greater than 70% of nights over a 30-day period must be documented. Individuals treated with an oral appliance require documentation that OSA is controlled with its use. Complex OSA, central sleep apnea, or OSA that requires advanced modes of ventilation such as adaptive servo-ventilation (ASV) or average volume assured pressure support (AVAPS) is generally non-deployable. Individuals using PAP therapy should deploy with a machine that has rechargeable battery back-up and sufficient supplies (air filters, tubing and interfaces/masks) for the duration of the deployment. Waivers are required as follows:

a. Asymptomatic mild OSA (diagnostic AHI and RDI < 15/hr): Deployable with or without treatment (PAP or otherwise). No waiver required.

b. Moderate to severe OSA (diagnostic AHI or RDI ≥15/hr), as well as symptomatic OSA (i.e. excessive daytime sleepiness) of any severity, require waiver as follows: Those individuals with confirmed compliance and reliable access to compatible power sources, as well as an absence of complex apnea, central apnea, need for advanced ventilation modes (as defined above), or additional disqualifying conditions do not require a waiver. If any of these factors are not adequately addressed, waiver is required.

14. History of clinically diagnosed traumatic brain injury (mTBI/TBI) of any severity, including mild. Waiver may not be required, but pre-deployment evaluation, which may include both neurological and psychological components, is required per ref X.

a. Individuals who have a history of a single mild Traumatic Brain Injury may deploy once released by a medical provider after 24-hours symptom free.

b. Individuals who have sustained a second mTBI within a 12-month period, may deploy after seven days symptom free and release by a medical provider.

c. Individuals who have had three clinically diagnosed TBIs (of any severity, including mild) must have neurological and psychological evaluation completed prior to deployability determination.

15. BMI > 40 with or without any significant comorbidity. Military personnel do not require waiver for BMI, but are subject to Service body fat guidelines and policy.

Individuals must be able to wear appropriate work uniforms and PPE. Morbid obesity can generally not be supported. A BMI calculator is located at http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

16. Asplenia, either actual or functional secondary to other medical condition. Waiver request should include verification of immunization against encapsulated bacterial pathogens (pneumococcus, meningococcus, Haemophilus influenza).

17. Gout, with two or more flares in the preceding year.

18. Multiple Sclerosis. Waiver requests should address stability of condition, current limitations. increased vulnerability to heat injury, and possible requirement for medication waiver.

19. Any medical condition (except OSA-see 13 above) that requires durable medical equipment or appliances (e.g., nebulizers, catheters, spinal cord stimulators), or that requires periodic evaluation/treatment by medical specialists not readily available at any theater location.

http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

20. Conditions requiring service animals or comfort animals. Does not apply to Military Working Dogs/Contract Working Dogs (see MOD 15, section 15.C.1.G.). Animals deployed to support behavioral health operations must deploy from CONUS as part of an official program with full logistic support and uniformed handlers.

B. Cardiovascular Conditions:

1. Symptomatic coronary artery disease.

2. Myocardial infarction within one year of deployment.

3. Coronary artery bypass graft, coronary artery angioplasty, carotid endarterectomy, other arterial stenting, or aneurysm repair within one year of deployment.

4. Cardiac dysrhythmias or arrhythmias, either symptomatic or requiring medication, electro-physiologic control, or automatic implantable cardiac defibrillator or other implantable cardiac devices.

5. Heart failure or history of heart failure.

6. Blood pressure and lipids should be considered and treated in the context of overall cardiac risk, for which a waiver may be required (see B. 7). Isolated hypertension or lipids do not require separate waiver except in the following circumstances:

a. Hypertensive urgency or emergency within previous 90 days.

b. 3 day average SBP > 140, DBP > 90.

c. Total Cholesterol >300, or Triglycerides >1000.

7. Civilian personnel who are 50 years of age or older must have a 10-year CHD risk percentage calculated (online calculator is available at http://tools.acc.org/ASCVD-Risk- Estimator/). If the individual’s calculated 10-year CHD risk is 15% or greater, the individual should be referred for further cardiology work-up and evaluation, to include some form of functional assessment (i.e. graded exercise stress test with a myocardial perfusion scintigraphy (SPECT scan) or stress echocardiography as determined by the evaluating cardiologist). Results of the evaluation and testing, along with the evaluating cardiologist’s recommendation regarding suitability for deployment, should be included in the waiver request.

C. Infectious Disease:

1. Confirmed Blood-borne diseases (Hepatitis B, Hepatitis C, HIV) which may be transmitted to others in a deployed environment. Waiver requests for persons testing positive for a blood borne disease, including positive antigens and viral load positive members, should include a full test panel for the disease, including all antigens, antibodies, viral load, and appropriate tests for affected organ systems.

2. Confirmed HIV infection is disqualifying for deployment, IAW References I and S, Service specific policies, and agreements with host nations. Note that some nations within the CENTCOM AOR have legal prohibitions against entering their country(ies) with this diagnosis.

3. Latent tuberculosis infection (LTBI). Individuals who are newly diagnosed with LTBI by either TST or IGRA testing will be evaluated per Service specific protocols and will have documented LTBI evaluation and counseling for consideration of treatment. Lack of treatment for LTBI is not a contraindication for deployment into the CENTCOM AOR and no waivers are required for a diagnosis of LTBI if appropriate Service specified evaluation and counseling, as noted above, is completed.

4. History of active tuberculosis (TB). Must have documented completion of full treatment course prior to deployment. Those currently on treatment for TB disease may not deploy.

5. A CENTCOM waiver cannot override host or transit nation infectious disease or immunization restrictions. Active duty must comply with status of forces agreements;

civilian deployers should contact the nation's embassy for up-to-date information.

D. Eye, Ear, Nose, Throat, Dental Conditions:

1. Vision loss. Best corrected visual acuity which does not meet minimum occupational requirements to safely perform duties. Bilateral blindness or visual acuity that is unsafe for the combat environment per the examining provider.

2. Refractive eye surgery. Personnel who have had laser refractive surgery must have a satisfactory period for post-surgical recovery before deployment. There is a large degree of patient variability which prevents establishing a set timeframe for full recovery. The attending ophthalmologist or optometrist will determine when recovery is complete.

a. Personnel are non-deployable while still using ophthalmic steroid drops post-procedure.

b. Personnel are non-deployable for three months following uncomplicated photorefractive keratectomy (PRK) or laser epithelial keratomileusis (LASEK), or one month for laser-assisted in situ keratomileusis (LASIK) unless a waiver is granted.

c. Waiver request should include clearance from treating ophthalmologist or optometrist.

3. Hearing loss. Service members must meet all Service-specific requirements or have completed a medical board and found fit for duty do not require a waiver. Individuals with sufficient unaided hearing to perform duties safely, hear and wake up to emergency alarms unaided, and hear instructions in the absence of visual cues such as lip reading do not require waiver. If ability to perform duties is in question, Speech Recognition In Noise Test (SPRINT) or equivalent testing should be included to verify this ability.

4. Tracheostomy or aphonia.

5. Patients without a dental exam within 12 months of deployment, or those who are likely to require evaluation or treatment during the period of deployment for oral conditions that are likely to result in a dental emergency. Individuals being evaluated by a non-DoD civilian dentist should use a DD Form 2813, or equivalent, as proof of dental examination.

6. Orthodontics requiring follow-up or adjustment while deployed. Those with wires in neutral force and are cleared by the treating orthodontist do not require waiver.

E. Cancer:

1. Cancer for which the individual is receiving continuing treatment or which requires any subspecialist examination and/or laboratory/imaging testing during the anticipated duration of the deployment.

2. Precancerous lesions that have not been treated and/or evaluated and that require treatment/evaluation during the anticipated duration of the deployment.

3. Cancers which have not been in complete remission for at least a year, excluding non-melanoma skin cancers.

F. GASTROINTESTINAL SYSTEM:

1. Inflammatory bowel disease, including, but not limited to: Crohn’s disease; ulcerative colitis; ulcerative proctitis; regional enteritis; granulomatous enteritis.

2. Chronic hepatitis with impairment of liver function.

3. The presence of any ostomy (gastrointestinal or urinary).

G. Surgery:

1. Any medical condition that requires surgery or for which surgery has been performed, to include cosmetic, bariatric, and reconstructive procedures, and the patient requires ongoing treatment, rehabilitation or additional surgery/revision.

2. Individuals who have had surgery requiring follow up during the deployment period or who have not been cleared/released by their surgeon (excludes minor procedures).

3. Individuals who have had surgery (open or laparoscopic) within 6 weeks of deployment.

4. Special dietary and hygienic requirements resulting from surgery cannot be reliably accommodated and may be independently disqualifying.

H. Behavioral Health Conditions: Diagnostic criteria and treatment plans should adhere to

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and current professional standards of care. Waiver submission should include information on applicant condition, including history and baseline symptoms of known disorders, severity of symptoms with and without treatment, and likelihood to recur or deteriorate in theater if exposed to operational activity. See reference KK. Waiver required for all conditions listed below (list is not inclusive).

1. Psychotic and bipolar-spectrum disorders are strictly disqualifying.

2. Any DSM 5-diagnosed behavioral health disorder, to include personality disorders, with residual symptoms, or medication side effects, which impair social and/or occupational performance.

3. Any behavioral health condition that poses a substantial risk for deterioration and/or recurrence of impairing symptoms in the deployed environment.

4. Any behavioral health condition that requires periodic (beyond quarterly) counselling or therapy.

5. Chronic insomnia that requires regular or long-term use of sedative hypnotics / amnestics, benzodiazepines, and/or antipsychotics. PRN, or as needed, use of medication for this diagnosis must clarify frequency of actual use.

6. Anxiety disorders requiring use of benzodiazepines for management, or featuring symptoms of panic or phobia.

7. Post-Traumatic Stress Disorder, when causing impairment or not completely treated, or when therapy includes use of benzodiazepines without additional anxiety diagnosis.

Waiver submission should note if condition is combat-related, and, if so, comment on impact that return to the operational environment could have on applicant well-being and performance.

8. Gender dysphoria, when distressing enough to require treatment. Transgender without history of, or current requirement for, transition, and not associated with significant gender dysphoria is not disqualifying and does not require waiver. Underlying behavioral health, endocrine, and/or surgical issues (as applicable) should be stable and resolved, and all Service requirements must be met, to include the involvement of, and clearance by, Service Central Coordination Cell if transition is required. See Ref LL.

Transitioning personnel’s treatment course should be complete, preferably with DEERS marker change, and an adequate Real Life Experience (RLE) period should have occurred to ensure stability. Due to complex needs, those requiring or actively undergoing gender transition are generally disqualified until the process, including all necessary follow-up and stabilization, is completed.

9. Bulimia and anorexia nervosa.

10. Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD).

Evaluation and diagnosis should be appropriate per DSM 5 criteria, particularly if Class II stimulants are used for treatment. Specific clinical features or objective testing results should be included in waiver application for stimulant use. Dosages for medications should likewise be appropriate per DoHHS-CMS standards (REF MM), and justified by clinical presentation. Uncomplicated ADD/ADHD stable (treated with 0-1 non-controlled substance medication) for greater than 3 months without social or occupational impact do not require a waiver. Substantiated cases not meeting those criteria but with appropriate dosing may be adjudicated at the Service Component level, provided additional BH conditions or diagnoses requiring waiver are not present.

11. Behavioral health related hospitalization or self-mutilation within the last 12 months.

12. Suicidal Ideation or Suicide Attempt with the last 12 months.

13. Substance use causing social or occupational disruption or impairment, including enrollment in a substance abuse program (inpatient or outpatient, service specific substance abuse program) within the last 12 months, measured from time of discharge / completion of the program.

a. A post-treatment period of demonstrated stability is required, the length of which will depend on individual patient factors.

b. Substance use disorders (SUD), not in remission and/or actively enrolled in Service Specific substance abuse programs are not eligible for waiver.

c. SUD requiring regular use of reversal agents or antagonists (Naloxone, Suboxone, Methadone) cannot be supported. Single-dose issuances of Naloxone are not intrinsically disqualifying, but require clarification of underlying SUD issues.

d. Alcohol use disorder requiring pharmacotherapy for maintenance (Disulfiram, Naltrexone, Acamprosate) cannot be supported.

e. Alcohol use disorders requiring random testing or other monitoring are disqualifying.

14. Use of antipsychotics or anticonvulsants for stabilization of DSM IV or DSM-5 diagnoses.

15. Use of 3 or more psychotropics (e.g. antidepressants, anticonvulsants, antipsychotics, benzodiazepines) for stabilization or any psychotropics which require a psychiatrist or other specialist to manage.

16. Behavioral health disorders without demonstrated clinical stability of at least 3 months, as defined by (1) no significant recent deterioration in clinical condition, (2) no significant impairment in work or interpersonal functioning, (3) no significant risk of sudden incapacitation should condition relapse or recur, (4) no morbid, suicidal, or homicidal ideation, intent or plan, and (5) likely to impact immediate family. Recent changes in treatment regimen, including discontinuation, should be explained and support clinical stability as above.

17. Behavioral health disorders newly diagnosed during deployment do not immediately require a waiver or redeployment. Disorders deemed treatable, stable, and having no impairment of performance or safety by a credentialed mental health provider do not require a waiver to remain in theater.

a. Exceptions include diagnoses featuring bipolar, psychotic, or suicidal features.

These individuals should be redeployed at soonest opportunity via medical evacuation with appropriate escorts and per TRANSCOM guidelines.

b. Diagnoses requiring the prescription of CSA-scheduled controlled substances will require an approved waiver to obtain routine refills of medication.

I. Medications – Recently discontinued medications are considered to have had valid clinical indications, and should include verification of control of underlying conditions and reason for cessation. Medications included as “PRN”, or as needed, must include a description of typical use. Although not exhaustive, use of any of the following medications (specific medication or class of medication) is disqualifying for deployment, unless a waiver is granted:

1. Any medication which, if lost, misplaced, stolen, or destroyed, would result in significant worsening or grave outcome for the affected individual before the medication could be reasonably replaced.

2. Any medication requiring periodic laboratory monitoring, titrated dosing, or special handling/storage requirements, or which has documented side effects, when used alone or in combination with other required therapy, which are significantly impairing, or which impose an undue risk to the individual or operational objectives.

3. Blood modifiers:

a. Therapeutic Anticoagulants: warfarin (Coumadin), rivaroxaban (Xarelto), apixaban (Eliquis).

b. Platelet Aggregation Inhibitors or Reducing Agents: clopidogrel (Plavix), anagrelide (Agrylin), Dabigatran (Pradaxa), Aggrenox, Ticlid (Ticlopidine), Prasugrel (Effient), Pentoxifylline (Trental), Cilostazol (Pletal), Ticagrelor (Brilinta). Note: Aspirin use in theater is to be limited to individuals who have been advised to continue use by their healthcare provider for medical reasons;

such use must be documented in the medical record.

c. Hematopoietics: filgrastim (Neupogen), sargramostim (Leukine), erythropoietin (Epogen, Procrit).

d. Antihemophilics: Factor VIII, Factor IX, Factor Xa.

4. Antineoplastics (oncologic or non-oncologic use): e.g., antimetabolites (methotrexate, hydroxyurea, mercaptopurine, etc.), alkylators (cyclophosphamide, melphalan, chlorambucil, etc.), antiestrogens (tamoxifen, etc.), aromatase inhibitors (anastrozole, examestane, etc.), medroxyprogesterone (except use for contraception), interferons, etoposide, bicalutamide, bexarotene, oral tretinoin (Vesanoid).

5. Immunosuppressants: e.g., chronic systemic steroids.

6. Biologic Response Modifiers (immunomodulators): e.g., abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), etanercept (Enbrel), infliximab (Remicade), leflunomide (Arava), azathioprine (Imuran), etc.

7. Antiretrovirals used for Pre-Exposure Prophylaxis (PrEP): e.g. tenofovir disoproxil fumarate/emtricitabine (Truvada)

8. Any CSA Schedule I-V controlled substance, including but not limited to the following:

a. Benzodiazepines: lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium), flurazepam (Dalmane), clonazepam (Klonopin), etc.

b. Stimulants: methylphenidate (Ritalin, Concerta), amphetamine/dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), dexmethylphenidate (Focalin XR), lisdexamfetamine (Vyvanse), modafinil (Provigil), armodafinil (Nuvigil), etc.

c. Sedative Hypnotics/Amnestics: zolpidem (Ambien, Ambien CR), eszopiclone (Lunesta), zaleplon (Sonata), estazolam (Prosom), triazolam (Halcion), temazepam (Restoril), etc. Note: single pill-count issuances for operational transition do not require a waiver.

d. Narcotics/narcotic combinations: oxycodone (Oxycontin, Percocet, Roxicet), hydrocodone (Lortab, Norco, Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), tramadol (Ultram), etc.

e. Cannabinoids: marijuana, tetrahydrocannabinol (THC), dronabinol (Marinol), cannabinol (CBD oil), etc. Note that possession or use may be a criminal offense in the CENTCOM AOR.

f. Anorexiants: phendimetrazine (Adipost), phentermine (Zantryl, Adipex-P), etc.

g. Androgens and Anabolic Steroids: testosterone (Axiron, AndroGel, Fortesta, Testim), oxymetholone (Anadrol-50), methyltestosterone (Methitest), etc.

Preparations used in accordance with standards outlined in 7.A.8 above do not require separate waiver.

9. Antipsychotics, including atypical antipsychotics: haloperidol (Haldol), fluphenazine (Prolixin), quetiapine (Seroquel), aripiprazole (Abilify), lurasidone (Latuda), ziprasidone (Geodon), olanzapine (Zyprexa), etc.

10. Antimanic (bipolar) agents: e.g., lithium.

11. Anticonvulsants, used for seizure control or behavioral health diagnoses.

a. Anticonvulsants (except those listed below) which are used for non-behavioral health diagnoses, such as migraine, chronic pain, neuropathic pain, and post-herpetic neuralgia, are not intrinsically deployment-limiting as long as treated conditions meet the criteria set forth in this document and accompanying MOD FIFTEEN. No waiver required. Exceptions include:

b. Valproic acid (Depakote, Depakote ER, Depacon, divalproex, etc.).

c. Carbamazepine (Tegretol, Tegretol XR, etc.).

d. Lamotrigine (Lamictal)

12. Dopamine agonists: Ropinirole (Requip), pramipexole (Mirapex), etc.

13. Botulinum toxin (Botox): Current or recent use to control severe pain.

14. Insulin and exenatide (Byetta).

15. Injectable medications of any type, excluding epinephrine (Epipen), medroxyprogesterone acetate (Depo-Provera), and testosterone cypionate (for Low T/hypogonadism), though underlying allergy may require separate waiver.

8. CONTACTS FOR WAIVERS (See also MOD 15, Para. 15.C.3.C.)

A. CENTCOM. CENTCOM.MACDILL.CENTCOM-HQ.MBX.CCSG-WAIVER@MAIL.MIL; CML:

813.529.0361/0348; DSN: 312.529.0361/0348

B. AFCENT. SG.SHAW@AFCENT.AF.MIL; CML: 803.717.7101; DSN: 313.717.7101

C. ARCENT. USARMY.SHAW.USARCENT.MBX.SURG-WAIVER@MAIL.MIL; CML: 803.885.7946;

DSN: 312.889.7946

D. MARCENT. USMARCENT.WAIVER@USMC.MIL; CML: 813.827.7175; DSN: 312.651.7175

mailto:CENTCOM.MACDILL.CENTCOM-HQ.MBX.CCSG-WAIVER@MAIL.MIL mailto:sg.shaw@afcent.af.mil mailto:USARMY.SHAW.USARCENT.MBX.SURG-WAIVER@MAIL.MIL

E. NAVCENT. CUSNC.MEDWAIVERS@ME.NAVY.MIL; CML: 011.973.1785.4558; DSN:

318.439.4558

F. SOCCENT. SOCCENT.SG@SOCOM.MIL; CML: 813.828.7351; DSN: 312.968.7351

mailto:CUSNC.MEDWAIVERS@ME.NAVY.MIL mailto:SOCCENT.SG@SOCOM.MIL