TRICARE Prime offers cost-effective health care coverage for active duty personnel, their families, as well as retirees and their dependent family members. However, according to TRICARE, if you do not obtain specialty-care referrals from your Primary Care Manager, you will be responsible for forking out for higher out-of-pocket medical expenses. The best way to avoid these added expenses is to get a referral from your Primary Care Manager.
Managing Referral Requests
If you require specialty care, you must receive a referral from your Primary Care Manager, who will put in a request for a referral on your behalf to a military clinic/ hospital or to a civilian provider for treatment. Once your referral has been authorised by TRICARE, you will be notified of the name as well as details relating to the services offered by the provider. You are then free to contact the specialty-care provider to make an appointment. Make sure you follow any special instructions in referral such as informing TRICARE of the date of your appointment.
Obtaining Additional Referrals
Some medical conditions necessitate repeated referrals in order to treat the medical condition. If your specialist recommends additional treatment, your Primary Care Manager and TRICARE will need to authorise additional referrals. Make sure you consult your Primary Care Manager for more information on additional referrals.
If you do not receive additional authorisation for referrals, you could find yourself using the TRICARE point-of-service (POS) option, which is a service that will mean an annual deductible for outpatient care, as well as higher cost-shares for inpatient and outpatient care.
Active Duty Patients
Active duty patients are usually required to receive non-emergency medical care only from their Primary Care Managers. According to TRICARE, TRICARE Prime family members (including military retirees) do not usually require referrals for the first eight outpatient behavioural health care visits during each fiscal year or for certain preventative services that they need.
TRICARE Prime beneficiaries who require referrals for specialty-care should consult their Primary Care Manager and receive approval from TRICARE. Patients who require additional specialty treatment should obtain additional referrals and follow instructions from TRICARE. The exception is with regard to active duty patients, who are usually required to receive all of their non-emergency medical care from their Primary Care Manager at the military installation.