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News | June 21, 2022

Have TRICARE Prime? Point-of-Service Option May Offer Some Flexibility

By TRICARE Communications

Do you have a TRICARE Prime plan? If so, your primary care manager (PCM) handles all your routine care. For specialty care, your PCM provides you a referral. However, there’s another way to seek care from a specialist without a referral. It’s called the point-of-service (POS) option.
 
“The point-of-service option offers TRICARE Prime enrollees the flexibility to see the doctors you want but at a higher cost,” said Shane Pham, program analyst with TRICARE Health Plan’s Policy and Programs Section at the Defense Health Agency. “If you want to access nonemergency care outside your network, the POS option allows you to visit any TRICARE-authorized provider other than your PCM, and no referral from your PCM is required.”
 
Before using the POS option, here are some main features you should know.
 
Who can use the POS option?
Active duty service members can’t use the POS option. However, all others enrolled in the following TRICARE Prime plans can use point-of-service:  
When can you use the POS option?
The POS option applies when you:
  • Receive care from a network or non-network TRICARE-authorized provider without a referral from your PCM
  • Receive care for clinical preventive services from a non-network provider. Keep in mind, clinical preventive services don’t require preauthorization or authorization if received by a network provider. If you don’t use a network provider for these services, then POS will apply.
  • Self-refer to a civilian specialty care provider after a referral is authorized to a military hospital or clinic specialty care provider
  • Self-refer to a non-network specialty care provider after a referral is authorized to a network specialty care provider
 
When can’t you use the POS option?
The POS option doesn’t apply for services that don’t require a referral. These include:  
What are the additional costs with using the POS option?
Using the POS option results in more out-of-pocket costs. When you use the POS option, you’ll pay point-of-service fees instead of your regular copayment, as well as any other fees that non-network providers may charge.
 
Point-of-service deductible
There is no annual deductible under the regular TRICARE Prime plan. However, as outlined in the TRICARE Costs and Fees Fact Sheet, the POS option has a deductible. This deductible only applies to outpatient claims. It doesn’t apply to inpatient claims.
The POS deductible is:
  • $300 per individual
  • $600 per family
 
Point-of-service cost-shares
What will you pay after you reach your deductible? Instead of a regular copayment, you’ll pay a cost-share. The POS cost-share is 50% of the TRICARE-allowable charge after the deductible is met. The TRICARE-allowable charge is the maximum amount TRICARE will pay a provider.
 
It’s also important to understand that POS costs don’t apply to your catastrophic cap. The catastrophic cap is the most you pay out of pocket each year for TRICARE covered services. This includes costs like enrollment fees, deductibles, copayments, and other cost-shares based on the TRICARE-allowable charge. Your regular TRICARE Prime costs will apply to your catastrophic cap.
 
You can review more detail about the point-of-service option and other costs by going to the Cost Terms page. To find your TRICARE costs, check out the TRICARE Compare Costs Tool.
 
Would you like the latest TRICARE news sent to you by email? Visit the TRICARE Subscriptions page today, and create your personalized profile to get benefit updates, news, and more.
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