Point of Service Option
The Point of Service (POS) option allows those enrolled in TRICARE Prime (excluding active duty service members), TRICARE Prime Remote for Active Duty Family Members (TPRADFM) or TRICARE Young Adult Prime to receive care from a TRICARE-authorized health care provider other than their primary care manager (PCM), without a referral.
The POS option does not apply to active duty service members and POS costs do not apply toward the catastrophic cap.
Using the POS option results in greater out-of-pocket expenses for beneficiaries:
(applies to outpatient services only)
|50% cost-share of the TRICARE allowable amount after the annual deductible is met.
Additionally, you may be responsible for up to 15% above the TRICARE allowed amount for a non-network provider.
|50% cost-share of the TRICARE allowable amount. Additionally, you may be responsible for up to 15% above the TRICARE allowed amount for a non-network provider.
When Point of Service Applies
The POS option is applied when:
- A TRICARE Prime, TPRADFM or TYA Prime beneficiary receives care from a network or non-network TRICARE-authorized provider without a referral from his or her PCM. Note: TPRADFM beneficiaries without an assigned PCM should contact Health Net Federal Services, LLC (HNFS) at 1-844-866-WEST (9378) to coordinate their specialty care.
- A TRICARE Prime, TPRADFM or TYA Prime beneficiary self-refers to a civilian specialty care provider after a referral has been authorized by HNFS to a military hospital or clinic specialty care provider.
- A TRICARE Prime, TPRADFM or TYA Prime beneficiary self-refers to a non-network specialty care provider after a referral has been authorized by HNFS to a network specialty care provider.
Note: Point of service will apply to all services within the beneficiary’s episode of care such as professional provider, ancillary, anesthesia, operating room, and other inpatient or outpatient facility services.
When Point of Service Does Not Apply
The POS option does not apply for services that do not require a referral such as:
- Emergency services
- Preventive care services from a network doctor
- Urgent care visits to network providers, or network or non-network (TRICARE-authorized) urgent care centers
- Beneficiaries whose other health insurance is primary
- Newborn or adoptee care (A newborn or adoptee is covered as a TRICARE Prime/TPRADFM beneficiary for the first 90 days after birth or adoption, as long as one additional family member is enrolled in TRICARE Prime/TPRADFM or the sponsor is active duty.)
- Ancillary services (for example, diagnostic radiology and ultrasound services, diagnostic nuclear medicine services, pathology and laboratory services, and cardiovascular studies) unless part of an episode of care that meets the POS requirements as listed above.
Note: Active duty service members who do not coordinate care through their PCM may be responsible for the entire cost of care.