FALLS CHURCH, Va.   –   Do you have TRICARE Prime? If so, you likely get most of your routine health care from your primary care manager. But sometimes, you may need specialty care that your PCM can’t provide. This is when your PCM will give you a referral. Having a referral can reduce your out-of-pocket expenses. Referrals can also help reduce the time you need to wait to get specialty care.

“If you have TRICARE Prime, referrals are important because they help you get the right care from the right providers,” said Jacob Sanchez, referral management subject expert, TRICARE Health Plan, at the Defense Health Agency. “Knowing how they work makes it easier to access the services you need and get the most out of your TRICARE benefit.”

In this article, you’ll learn about the TRICARE Prime referral process. We’ll highlight what’s new—and easier—for you and your family members if you’re moving this year.

If you used the West Region referral approval waiver to see a specialist between Jan. 1 and June 30 and need to continue seeing that specialist, you’ll need to get a new referral for your care before Oct. 1.
Keep reading to learn more and make the most of your TRICARE benefits.

How referrals work

Your provider starts the process by sending a referral request to your regional contractor. They review the referral request and, once processed, send you a notification in your beneficiary self-service portal. Then, you can contact the provider listed on the notification letter to make your appointment.

When to get a referral

Do you need a referral? It depends on your beneficiary category, your TRICARE plan, and the type of care you need.

• Active duty service members: You need a referral for any nonemergency care your PCM doesn’t provide. This includes specialty care and urgent care. If you get care without a referral, you may have to pay out of pocket.
• All others with a TRICARE Prime plan: You don’t need a referral for preventive care, urgent care, or most outpatient mental health care. You do need a referral for specialty care and some diagnostic services, as described in the TRICARE Plans Overview Fact Sheet. If you get this care without a referral, you’ll be using the point-of-service option. You’ll pay more out of pocket if you use this option.
• Do you live in the West Region? You won’t have to pay point-of-service fees for care received from a non-network provider through Sept. 30, as long as the provider is TRICARE-authorized. DHA has issued a temporary waiver for POS fees, as long as the provider is TRICARE-authorized. Starting Oct. 1, if the provider remains a non-network provider and isn’t named on your referral or authorization, POS fees will apply. This doesn’t apply if you live in the East Region or overseas.
• TRICARE For Life: You don’t need a referral for most health care services. But you may need pre-authorization for certain services.

You don’t need a referral to get emergency care. However, you should contact your PCM the next business day after you get emergency care.

Other helpful referral tips

Second opinions

Do you have concerns or questions after seeing a specialist for care? Are you unsure about a diagnosis or treatment option? You have the right to request a second opinion. With TRICARE Prime, you should request a second opinion through your PCM.

Referrals expire

Don’t forget that referrals have expiration dates. Make sure to schedule your appointment and get care before your referral expires. You can find the expiration date on your notification letter. If your referral expires and you need a new one, contact your PCM.
When you get a referral for specialty care, you can expect to get an appointment within 28 days.

(Note: Do you have an active referral issued in the West Region before Jan. 1, 2025? You can keep seeing the specialist listed on the referral through its expiration date, or Sept. 30, whichever comes first.)

New in 2025: Transferring referrals within and between regions

Are you moving to another location in the U.S.? Whether your sponsor has recently gotten permanent change of station orders, or you’re moving for personal reasons—there’s good news about moving with your TRICARE coverage.

You can now transfer your active referrals within the same region, or between the East and West Region. You don’t have to see a new PCM to get a new referral first. This means fewer disruptions to your specialty care while you’re waiting to see a new PCM.

IMPORTANT: Before you move, call your current regional contractor and request that your valid, active referrals be transferred to your new regional contractor.

If you’re moving to a different region:

Do you have any active referrals? Your referrals will still be valid in your new location. (Note: This doesn’t apply if you have an active referral you received with the current referral approval waiver in the West Region.)

Before you move, call the regional contractor in your current location to request your active, valid referrals be transferred to the regional contractor for your new location. Your regional contractor will forward valid approved referrals to the regional contractor you’re moving to, when you or your provider requests your referrals be transferred.

Here are the steps you should follow:

1. After your move, update your enrollment within 90 days. Log in to milConnect and choose Beneficiary Web Enrollment from the Benefits menu. Update your enrollment based on your new address, so that DEERS shows that you’re in your new location
2. Once you’re enrolled in your new region, create a beneficiary portal account.
   • East Region beneficiary portal
   • West Region beneficiary portal

3. Contact your new regional contractor. Ask them to create a new specialty referral in your new location for the active specialty referrals that were transferred. This will help you continue your specialty care without delay.

4. Your new contractor will generate new specialty referrals to a new specialty provider based on your location. (Note: Your specialty referral may be assigned to a military hospital or clinic in your new location, if the military hospital or clinic is able to provide the care.)
5. You may view your authorization letter online in your beneficiary portal.
6. Call to schedule an appointment with the new specialty provider’s office.

Contact your regional contractor with questions about referrals:

• West Region: 888-TRIWEST (874-9378)
• East Region: 800-444-5445

Important: Did you use the referral approval waiver to see a specialist in the West Region from Jan. 1 through June 30? If TriWest Healthcare Alliance never processed your referral, you’ll need to get a new referral from a PCM in the East Region.

If you’re moving within the same region:

1. After your move, update your enrollment within 90 days. Log in to milConnect and choose Beneficiary Web Enrollment from the Benefits menu. Your update will trigger the DMDC/DEERS Support Office to notify your regional contractor about your address change. NOTE: If you need help, contact your regional contractor.
2. Call your regional contractor. Ask them to create a new specialty referral in your new location, to see a new specialist. (Note: Your specialty referral may be assigned to a military hospital or clinic in your new location, if the military hospital or clinic is able to provide the care.)

Do you or a family member get services through the Autism Care Demonstration or Extended Care Health Option? You should contact your new regional contractor to let them know. Once your new contractor identifies a new case manager, your previous case manager will work with your new one to ensure a warm handoff of services.

Unlock your health with knowledge that TRICARE has you covered. To learn more about referrals, visit TRICARE Referrals and Pre-Authorizations.

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