TRICARE covers millions of military families. Your plan, your costs, and what you can do depend heavily on your beneficiary category. This guide explains the system and how to use it.
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Plans and enrollment · Which plan
Which plan do you have?
TRICARE is not one plan. It is a family of health plans administered by the Defense Health Agency. The plan you have depends on your beneficiary category: active duty family member, retiree, reservist, young adult, or Medicare-eligible retiree.
TRICARE Prime
HMO-style. You select a primary care manager (PCM) and get referrals for specialty care. Lowest out-of-pocket costs. Active duty families pay no enrollment fee. Retirees pay an annual fee (Group A: $381.96 individual / $765 family in 2026). You must live within a Prime service area.
TRICARE Select
PPO-style. More provider flexibility, higher out-of-pocket costs. No PCM required, no referrals needed. You can see any TRICARE-authorized provider. Active duty families pay no enrollment fee. Retirees pay a lower fee than Prime (Group A: $186.96 / $375 family in 2026).
TRICARE For Life (TFL)
For military retirees who are Medicare-eligible (have both Part A and Part B). Medicare pays first; TRICARE pays most or all of what Medicare does not. Requires Medicare Part B. No additional TRICARE enrollment fee.
TRICARE Reserve Select (TRS)
For Selected Reserve members not on active duty. Premium-based: $57.88/month member only, $286.66/month member + family in 2026. Full TRICARE benefit.
TRICARE Retired Reserve
For retired Reserve members under age 60 who are not yet eligible for regular retiree TRICARE. $645.90/month individual, $1,548.30/month family in 2026.
TRICARE Young Adult (TYA)
For adult children ages 21-26 who aged off regular TRICARE. Premium-based: Prime $794/month or Select $363/month in 2026. Requires no other health coverage.
Group A vs Group B
Your group depends on when your sponsor first entered military service. Group A: before January 1, 2018 (lower costs). Group B: January 1, 2018 or later (slightly higher costs). This distinction applies to Prime and Select enrollment fees, deductibles, copays, and catastrophic caps.
Your TRICARE ID card proves your eligibility to providers. You receive it automatically when you register in DEERS. The card your sponsor carries is different from the card a family member uses.
What it shows
Your name, sponsor ID, beneficiary category, and the plan year. Some providers also need your sponsor's Social Security Number last four digits for verification.
Common ID card (CAC)
Active duty service members use their Common Access Card as their TRICARE ID. Family members receive a separate ID card.
Your uniformed services ID card
Dependents and retirees receive a uniformed services ID card that serves as their TRICARE credential. Obtain one at any Real ID-compliant military installation.
Lost or damaged card
Report to your nearest DEERS/RAPIDS site or call 1-800-538-9552 (DEERS Support Office). Bring documentation of your relationship to the sponsor. Find a RAPIDS site at rapids.dmdc.osd.mil.
Digital ID
The milConnect portal (milconnect.dmdc.osd.mil) provides a digital version of your ID documentation for most situations.
Verify your DEERS record whenever your status changes
Marriage, birth, adoption, divorce, or separation should all trigger a DEERS update immediately.
Plans and enrollment · DEERS
DEERS enrollment
The Defense Enrollment Eligibility Reporting System (DEERS) is the database that determines who is eligible for military benefits including TRICARE. If you are not in DEERS correctly, you are not covered.
1
Confirm you are enrolled correctly
Active duty members are enrolled automatically. Dependents must be registered by the sponsor at a RAPIDS site (rapids.dmdc.osd.mil) or through milConnect. Retirees must also be enrolled.
2
Enroll or update within 60 days of a qualifying event
Marriage, birth, adoption, and other life events give you 60 days to add a dependent. Missing this window means waiting until the next Open Season.
3
Keep your address current in DEERS
DEERS address is used for TRICARE communications, including EOBs and plan notices. Update at milConnect or any RAPIDS site.
4
Verify your record before moving or retiring
DEERS discrepancies are the most common reason TRICARE claims get denied. Audit your record before any major status change.
TRICARE costs and plan options depend heavily on your category. The same plan can cost very different amounts depending on who you are.
Active duty service members
Full TRICARE coverage at no cost. Assigned to TRICARE Prime. No enrollment fees, no copays. Your family members are active duty family members with their own category.
Active duty family members
Can enroll in Prime or Select at no enrollment fee. Small copays apply for Prime if using point-of-service option. Select has a deductible and cost-shares.
Retirees and their families
Pay enrollment fees for Prime or Select. Costs depend on Group A or B status. For retirees who qualify for Medicare, TRICARE For Life applies.
Selected Reserve and their families
Must purchase TRICARE Reserve Select (TRS) at a monthly premium. Full TRICARE benefit package.
Retired Reserve (under 60)
Must purchase TRICARE Retired Reserve at a higher monthly premium. Transitioning to regular retiree TRICARE at age 60.
Adult children 21-26
Can purchase TRICARE Young Adult at $363/month (Select) or $794/month (Prime) in 2026. Must not be eligible for employer coverage.
Survivors
Surviving spouses and dependent children of service members who died on active duty receive transitional TRICARE coverage. Survivors of retirees retain retiree category coverage.
Plans and enrollment · TFL
TRICARE For Life
TRICARE For Life (TFL) is for military retirees and their eligible family members who have Medicare Part A and Part B. TFL acts as secondary coverage to Medicare, paying most or all of what Medicare does not. It is one of the strongest supplemental coverage options available.
Eligibility
You must be a military retiree (or eligible dependent) AND have both Medicare Part A and Part B. You are automatically enrolled in TFL when you become Medicare-eligible if you are already registered in DEERS.
How it works
Medicare pays first for Medicare-covered services. TFL pays second, covering most of Medicare's cost-sharing (deductibles, copays, coinsurance). For most services, your out-of-pocket cost is $0.
No TRICARE enrollment fee
TFL has no separate premium beyond Medicare Part B ($202.90/month in 2026). The combined Medicare Part B premium plus $0 TFL fee is your total premium.
Pharmacy under TFL
TFL covers prescriptions not covered by Medicare Part D. Military pharmacy (MTF) is still available at no cost. Use home delivery ($12/$34/$68 for 90-day supplies) or retail network ($14/$38/$68 for 30-day) for prescriptions Medicare does not cover.
Overseas TFL
When you travel or live overseas, TFL becomes the primary payer since Medicare generally does not cover overseas care. Standard TRICARE overseas cost-sharing applies.
Coordination of benefits
Always give both your Medicare and your TRICARE information to every provider. Most Medicare-accepting providers will bill Medicare first; TRICARE adjudicates the remainder automatically.
Medicare Part B is required for TFL
If you drop Medicare Part B, you lose TRICARE For Life. There is no exception. Many retirees have lost TFL this way by trying to avoid the Part B premium.
Providers and care · Finding a provider
Finding a network provider
TRICARE works differently on Prime versus Select. On Prime, you start with your primary care manager (PCM). On Select, you can see any TRICARE-authorized provider without a referral. In both cases, verifying network status before your visit prevents unexpected costs.
1
Use the TRICARE Find a Doctor tool
Go to tricare.mil/FindADoctor. Select your region and plan type. The tool shows network providers by specialty. Print or save the search results.
2
Call the provider directly to confirm
TRICARE provider directories can be 30-90 days behind. Always call the provider and ask: "Do you accept TRICARE [your plan type]?" Online directories are a starting point, not a guarantee.
3
On Prime: use your PCM for referrals
Your PCM coordinates all your specialty care. Self-referring to a specialist on Prime triggers the point-of-service (POS) option with significantly higher cost-sharing.
4
On Select: any TRICARE-authorized provider
No PCM, no referrals required. You pay network cost-shares for network providers and higher cost-shares for non-network (but authorized) providers.
Military treatment facilities (MTFs) are on-base hospitals and clinics. For Prime enrollees who live near an MTF, it may be your assigned PCM location. Care at MTFs is always at no cost.
Care at MTFs is $0
No copay, no cost-share for any covered service at a military treatment facility. For Prime enrollees assigned to an MTF, this is your default care setting.
Space-available care
If you are not enrolled at an MTF, you may still be able to get care there on a space-available basis. Active duty family members and retirees can both seek space-available care, but it is not guaranteed.
Priority order at MTFs
Active duty service members have first priority. Active duty family members come second. Retirees and their families are third. Space-available care is offered after required care is fulfilled.
MTF pharmacy
The military pharmacy at an MTF is always the cheapest option: $0 for covered formulary drugs. Highly recommended for ongoing medications.
Transitioning away from MTF care
If your MTF loses capability for a certain service, or if you move out of the area, TRICARE will refer you to a civilian network provider automatically.
Find your nearest MTF
Use tricare.mil/FindADoctor and filter by "Military Hospital/Clinic." Or ask your installation's health benefits advisor.
Providers and care · Urgent care
Urgent care
TRICARE covers urgent care at network urgent care centers for non-emergency situations. This is faster and cheaper than an emergency room for most conditions.
What counts as urgent care
Illnesses or injuries that need attention within 24 hours but are not life-threatening: ear infections, minor cuts, sprains, UTIs, mild respiratory illness. For true emergencies, go to the nearest ER.
Cost on Prime (2026)
$20 copay at a network urgent care center for active duty families. Retirees: $35. No referral needed for urgent care on Prime.
Cost on Select (2026)
Cost-share applies after the deductible is met. Network provider: 20% of allowed charges. Retirees may pay more.
Find a network urgent care center
Use tricare.mil/FindADoctor and filter by "Urgent Care." Not all urgent care centers accept TRICARE. Always verify before arriving.
Emergency care differs
True emergencies are covered at any ER worldwide with no prior authorization needed. You must notify TRICARE within 24 hours of emergency care.
Point-of-service on Prime
If you use a non-network urgent care center on Prime, you are using the point-of-service (POS) option. You will pay 50% of the TRICARE-allowed charge plus an annual POS deductible ($300 individual / $600 family in 2026).
Call TRICARE Nurse Advice Line first for guidance
Available 24/7 at 1-800-874-2273. Can help you decide if urgent care, ER, or wait is appropriate for your situation.
Providers and care · Mental health
Mental health and behavioral health
TRICARE covers a broad range of mental health services including therapy, psychiatry, inpatient care, and substance use treatment. Access rules have been relaxed so you can see a network mental health provider directly on Prime without a referral in most circumstances.
Self-referral to mental health on Prime
You do not need a PCM referral to see a network licensed independent mental health provider (LIMHP) for the first eight visits per calendar year. After eight visits, your provider should coordinate with your PCM.
Covered services
Individual, group, and family therapy; psychiatry and medication management; inpatient psychiatric care; intensive outpatient programs; partial hospitalization; substance use disorder treatment.
Telehealth mental health
TRICARE covers telehealth mental health services. Many network providers offer video appointments. Especially valuable when deployed, on remote bases, or between duty stations.
Student behavioral health
TRICARE covers behavioral health services at accredited college counseling centers for eligible student dependents. Useful for young adults on TYA or still on parent coverage.
Military OneSource
Free short-term counseling (up to 12 sessions) for service members and families. Does not count against TRICARE benefits. Call 1-800-342-9647 or visit militaryonesource.mil.
Crisis resources
Military Crisis Line: dial 988 then press 1. Text 838255. Chat at veteranscrisisline.net. For non-veteran active duty and family members: Military Crisis Line also serves you.
Providers and care · Overseas
Care overseas
TRICARE covers care outside the United States, but the rules differ from stateside care. TRICARE Overseas Program (TOP) handles claims for care received outside the U.S. and its territories.
TRICARE Prime Overseas and Prime Remote Overseas
For active duty members and their families stationed OCONUS. Functions like Prime stateside with a designated overseas PCM.
TRICARE Select Overseas
For retirees and others living overseas who are not in Prime Overseas. Broader provider access; claims submitted to the International SOS contractor.
TRICARE For Life overseas
TFL acts as primary payer overseas since Medicare generally does not cover overseas care. Standard TFL cost-sharing applies.
Filing claims overseas
Find a local provider, pay out of pocket, then submit a claim to the overseas TRICARE contractor (International SOS). Keep all receipts and documentation. Reimbursement typically takes 30-60 days.
Host nation providers
Any licensed provider in the host country qualifies. TRICARE will reimburse based on allowed charges. Language access can be a challenge; the TRICARE contractor can help with translation in some cases.
Emergency care anywhere
Emergency care is covered anywhere in the world without prior authorization. Notify TRICARE within 24 hours of emergency admission when possible.
TRICARE provides comprehensive medical and mental health coverage. The benefit package is consistent across plan types though what you pay varies significantly. The following services are covered under all TRICARE plans.
Preventive care
Annual physical exams, immunizations, cancer screenings, well-woman exams, well-child care. Active duty family members and most preventive services are covered at $0 under Prime.
Primary care
Routine office visits, chronic disease management, sick visits. Cost depends on plan and beneficiary category.
Specialty care
Referral from PCM required on Prime. Self-refer on Select. Covered specialties include cardiology, oncology, orthopedics, dermatology, and all others.
Mental and behavioral health
Broad coverage including therapy, psychiatry, inpatient, substance use. Self-referral to network mental health on Prime up to 8 visits per year.
Hospital care
Inpatient medical and surgical care, intensive care, maternity. Cost-sharing varies by plan and beneficiary category.
Emergency care
Any emergency worldwide, any provider, no authorization needed. Notify TRICARE within 24 hours when possible.
Maternity care
Full prenatal, delivery, and postpartum care. Covered for the beneficiary; newborn coverage begins automatically from birth.
Durable medical equipment
Wheelchairs, prosthetics, orthotics, CPAP machines, and other prescribed equipment. Prior authorization often required for higher-cost items.
Home health
Skilled nursing, physical therapy, occupational therapy, speech therapy in the home when medically necessary after hospitalization or injury.
Active duty members have no out-of-pocket costs
Active duty service members pay $0 for any covered service. Cost-sharing only applies to family members and retirees.
Coverage and benefits · Dental
Dental coverage
Dental coverage under TRICARE depends entirely on your beneficiary category. Active duty members get comprehensive dental at no cost. Everyone else needs to understand what program applies to them.
Active duty: Uniformed Services active duty dental
Full dental care at no cost through military dental facilities (MTF dental clinics). All treatment including complex procedures covered.
Active duty family members: TRICARE Dental Program (TDP)
A premium-based dental plan. Enrollees pay monthly premiums and then cost-shares. Premiums as of 2026: $14.99/month for one adult; $35.50 for family. Covers preventive, basic, and major dental.
Retirees and their families
Not covered by basic TRICARE. Must enroll in TDP separately or obtain dental coverage through FEDVIP (if applicable) or a private dental plan. TDP accepts retirees.
Reserve and Guard members on active duty
Covered by active duty dental program while on active duty orders of 30 days or more. Otherwise, TDP is available for purchase.
TDP enrollment
Enroll at benefeds.com. Coverage requires enrollment; it does not happen automatically. 12-month commitment required except for qualifying life events.
Basic TRICARE covers vision care only when medically necessary. Routine eye exams and glasses are not included in standard TRICARE. For that, you need a separate vision plan.
Medically necessary vision care
Eye diseases (glaucoma, diabetic retinopathy, macular degeneration), injury, and post-surgical care are covered under TRICARE as medical care. Diagnosis and treatment of eye conditions is covered.
Routine exams and eyewear: NOT covered by standard TRICARE
Annual wellness eye exams, eyeglasses, and contact lenses are not part of the standard TRICARE benefit.
TRICARE Young Adult vision
TYA also excludes routine vision. Same gap applies.
FEDVIP vision plans
Federal employees and their families who are TRICARE-eligible may be able to enroll in FEDVIP vision. Available to active duty family members and retirees. Premiums are very low (2026 average increase only 0.47%).
TDP does not cover vision
The TRICARE Dental Program is dental only. Vision requires a separate enrollment.
Other options
VSP, EyeMed, and other private vision discount plans are available. Active duty service members can get exams at MTF optometry clinics for free.
Coverage and benefits · Pharmacy
Pharmacy benefits
TRICARE has one of the most cost-effective prescription drug programs available. The military pharmacy at an MTF is always $0 for covered formulary drugs. Home delivery through Express Scripts is the next cheapest option.
Military pharmacy (MTF)
$0 for all covered formulary drugs. Best option for anyone with an MTF nearby. 90-day supplies available for maintenance medications.
TRICARE Pharmacy Home Delivery (90-day supply, 2026)
Generic: $12. Brand-name formulary: $34. Non-formulary: $68. Use Express Scripts at express-scripts.com/TRICARE or 1-877-363-1303.
Retail network pharmacy (30-day supply, 2026)
Generic: $14. Brand-name formulary: $38. Non-formulary: $68. CVS, Walgreens, and most major chains participate.
Active duty family members on Prime Remote: $0 at retail
Starting February 28, 2026, active duty family members enrolled in TRICARE Prime Remote pay $0 at network retail pharmacies and home delivery for covered formulary drugs.
Non-formulary drugs
Require non-formulary copay at all fill sites. Your provider can request a formulary exception if medically necessary; this typically reduces the cost.
Step therapy
For some drug classes, TRICARE requires trying a lower-cost alternative first. Your provider can submit a step therapy exception with medical justification.
Transfer maintenance medications to home delivery
After two retail fills of the same maintenance medication, TRICARE may require home delivery. Set it up proactively through Express Scripts to avoid gaps.
Coverage and benefits · Gaps
What is not covered
TRICARE covers a comprehensive benefit package but several categories are explicitly excluded. Knowing the gaps prevents surprise bills and helps you plan alternative coverage where needed.
Routine dental and vision
Standard TRICARE does not cover annual eye exams, eyeglasses, or routine dental care. These require separate enrollment in TDP and/or a vision plan.
Cosmetic procedures
Not covered unless medically necessary after illness, injury, or surgery. The line between cosmetic and reconstructive can be appealed with proper documentation.
Experimental and investigational treatments
Treatments not approved by the FDA or not considered standard of care are generally excluded. Clinical trial participation may have separate coverage rules.
Alternative medicine (limited)
Acupuncture, chiropractic care, and other alternative treatments are covered only when provided by a licensed provider for specific conditions and in limited circumstances.
Custodial care
Non-skilled long-term care (help with daily living activities) is not covered. Skilled nursing, PT, OT, and speech therapy are covered when medically necessary.
Care not pre-authorized on Prime when required
Certain services require prior authorization on Prime. Getting that care without authorization means you pay the full cost (or point-of-service rates at minimum).
Care outside the benefit package
Services not in the TRICARE basic benefit package (certain elective procedures, weight loss programs not meeting criteria, etc.) are not covered regardless of plan type.
Verify before scheduling anything non-routine
Call TRICARE at 1-800-444-5445 or review your Evidence of Coverage before any procedure that is not clearly routine. Pre-authorization saves you from the largest surprise bills.
Costs and cost-sharing · 2026 overview
2026 cost overview
TRICARE costs are set annually by the Defense Health Agency. They took effect January 1, 2026. Most Prime and Select users saw increases of about 3%, in line with the 2.8% COLA.
Active duty service members
$0 for everything. No enrollment fee, no copays, no deductible, no cost-share. Full TRICARE Prime coverage at no cost.
Active duty family members on Prime (2026)
No enrollment fee. $0 copay for covered services at network providers. $20 copay for urgent care. Point-of-service: 50% of allowed charges plus POS deductible.
Retirees on Prime, Group A (2026)
Annual enrollment: $381.96 individual, $765 family. Primary care copay: $26. Specialty care copay: $40. Catastrophic cap: $3,000.
Enrollment fees are annual premiums paid to participate in a TRICARE plan. Not all beneficiary categories pay them. They are separate from monthly premiums for premium-based plans.
Who pays no enrollment fee
Active duty service members and active duty family members enrolled in Prime or Select pay no annual enrollment fee.
Retirees on Prime, Group A (2026)
$381.96/year individual, $765/year family. Billed monthly or quarterly.
Retirees on Prime, Group B (2026)
$462.96/year individual, $927/year family.
Retirees on Select, Group A (2026)
$186.96/year individual, $375/year family.
Retirees on Select, Group B (2026)
$594.96/year individual, $1,191/year family.
Frozen enrollment fees
If you are medically retired or a survivor of an active duty member, your enrollment fee is frozen at the rate in effect when you were classified. Stays frozen with continuous TRICARE Prime enrollment.
When enrollment fees are due
Payable when you enroll or at the start of each plan year. Can be paid by allotment (auto-deducted from retirement pay) or directly.
Costs and cost-sharing · Per-visit costs
Copays and cost-shares
A copay is a fixed dollar amount per visit (TRICARE Prime primarily uses copays). A cost-share is a percentage of the allowed charge after the deductible (TRICARE Select uses cost-shares). Understanding which applies to you prevents billing surprises.
Prime copays (network, 2026)
Active duty families: $0 most services. Retirees Group A: primary care $26, specialty $40, urgent care $35, ER $115. Group B: slightly higher.
Select cost-shares (network, 2026)
After the deductible is met: retirees pay 25% of TRICARE-allowed charges for network providers. Active duty families pay 20%.
Non-network select (2026)
After the non-network deductible: retirees pay 45% of TRICARE-allowed charges. Additional liability if provider balance-bills above the TRICARE maximum.
Point-of-service (Prime only)
Going to a non-network provider on Prime without a referral triggers POS: you pay 50% of allowed charges plus a POS deductible ($300 individual, $600 family) before POS benefits start.
Emergency care copays
Retirees on Prime or Select: $115 copay or 25% cost-share. No prior auth required for emergencies. Stabilization at an ER is covered regardless of authorization.
Lab and imaging
Ordered by your PCM or specialist: Prime usually $0 in-network. Select: cost-share after deductible.
Costs and cost-sharing · Deductible
Annual deductible
TRICARE Prime has no deductible. TRICARE Select has an annual deductible that must be met before cost-shares begin. The deductible differs by beneficiary category and group.
Prime: no deductible
No deductible for any covered service under TRICARE Prime. Copays apply from the first visit.
Select deductible, active duty families (2026)
Group A: $150 individual, $300 family. Group B (E-4 and below): $66 individual, $132 family. Group B (E-5 and above): $198 individual, $397 family.
Select deductible, retirees (2026)
Group A: $150 individual, $300 family. Group B: approximately $198 individual, $397 family.
What counts toward the deductible
Only allowed charges for covered services count. Balance-billed amounts above the TRICARE maximum do not count. Premium costs do not count.
Family deductible
Once the family deductible is met, individual deductibles within the family are waived for the rest of the year.
Deductible resets January 1
The deductible year runs January 1 to December 31. It does not carry over. Scheduling care that meets your deductible early in the year maximizes the benefit.
Costs and cost-sharing · Your annual maximum
Catastrophic cap
The catastrophic cap is the maximum amount you will pay out of pocket for covered TRICARE services in a calendar year. Once you hit it, TRICARE pays 100% of covered services for the rest of the year. It is your protection against catastrophic illness or injury.
Active duty family members (2026)
Group A: $1,000. Group B: $1,324. The lowest catastrophic cap reflects the deployment and operational sacrifices of active duty families.
Retirees, Prime, Group A (2026)
$3,000 per family per year. Once met, Prime pays 100% of covered network care.
Retirees, Select, Group A (2026)
$4,381 per family per year.
Group B retirees, Select (2026)
$4,635. Slightly higher than Group A.
What counts toward the cap
Enrollment fees, copays, deductibles, and cost-shares all count. Premium-based plan premiums (TRS, TRR, TYA) do not count toward the cap.
What does NOT count
Amounts balance-billed above the TRICARE maximum. Amounts for non-covered services. POS option charges in some circumstances.
TRICARE For Life
TFL beneficiaries have Medicare's catastrophic protection. TRICARE supplements Medicare, so catastrophic exposure is usually minimal. No separate TFL catastrophic cap applies.
Track your family's costs toward the cap each year
TRICARE EOBs show your running total. Once you are close to the cap, the math may favor front-loading remaining care for the year.
Referrals and appeals · Referrals
Referrals
On TRICARE Prime, your primary care manager (PCM) manages your care. Specialty visits require a referral from your PCM. On Select, no referrals are needed.
Who needs referrals
TRICARE Prime enrollees need referrals for all specialty care. Select enrollees do not. Mental health care: both Prime and Select can self-refer to a network mental health provider for initial visits.
How to get a referral on Prime
Call your PCM or contact your Regional Contractor (Humana Military or Health Net Federal Services). Referrals can be issued electronically and sent directly to the specialist.
Referral timing
Non-emergency specialty referrals should be processed within 28 days. Urgently needed care within 24 hours. Routine referrals within 7 days of the PCM visit.
Referral is not the same as prior authorization
A referral sends you to a specialist. Prior authorization is the insurance approval for the specific service or procedure. Both may be required.
What happens if you see a specialist without a referral on Prime
You are using the point-of-service option. You pay 50% of TRICARE-allowed charges plus the POS deductible. Always get the referral first.
Referral from MTF to civilian
When your MTF cannot provide a needed service, they issue a referral to a civilian TRICARE-authorized provider automatically. This is covered at normal Prime rates.
Referrals and appeals · Prior authorization
Prior authorization
Prior authorization (PA) is TRICARE's pre-approval for specific services or procedures before they are performed. Without it, you may owe the full cost of the service.
Services that commonly require PA
Inpatient hospitalization (non-emergency), most surgeries, high-cost imaging (MRI, CT, PET), skilled nursing facility, home health, durable medical equipment over $300, certain specialty drugs, gender-related services (where covered).
Who submits the PA
Your provider submits the PA request to TRICARE or your regional contractor. You should confirm that your provider has submitted it and received approval before the procedure.
Decision timeline
Routine PA: within 14 days. Urgent PA: within 72 hours. Emergency: no PA needed; notify TRICARE within 24 hours.
What PA approval means
PA approves the service in principle. It does not guarantee payment if other coverage issues arise (e.g., provider is out of network when you expected in-network).
PA denial
You or your provider can request reconsideration immediately. Medical necessity documentation greatly improves success rates. See the Appeals panel for the full process.
Checking PA status
Log in to milConnect or call your regional contractor: Humana Military (East) 1-800-444-5445, Health Net Federal Services (West) 1-844-866-9378.
Referrals and appeals · Denied
A service was denied
TRICARE denials happen for a few common reasons. Most are correctable. Start with the denial notice, understand the reason, and respond accordingly.
1
Read the denial notice carefully
TRICARE must send a written Explanation of Benefits (EOB) or denial letter stating the specific reason for denial. Common reasons: prior authorization not obtained, provider not authorized, service not covered, benefit limit reached.
2
Contact your provider
Many denials result from administrative errors on the provider side: wrong billing code, missing authorization number, wrong insurance on file. Providers can resubmit with corrections.
3
Request a reconsideration
For clinical denials (service deemed not medically necessary), ask your provider to submit additional medical records documenting the necessity. Reconsiderations are decided within 30 days.
4
File a formal appeal if reconsideration fails
Submit a written appeal to your TRICARE regional contractor within 90 days of the denial. Include a letter of medical necessity from your provider, supporting clinical documentation, and a copy of the denial letter.
TRICARE has a structured appeals process that gives you multiple opportunities to challenge a denial. Acting quickly at each stage matters because deadlines are short.
Step 1: Reconsideration
First administrative appeal. Submitted to your regional contractor within 90 days of the denial. Contractor must decide within 30 days. Your provider can submit on your behalf.
Step 2: Independent review
If reconsideration is denied, request independent medical review by a contractor not affiliated with your regional contractor. Submit within 30 days of the reconsideration denial.
Step 3: Formal hearing
For claims above $300. Request from your contractor within 60 days of the independent review denial. A hearing officer reviews the case.
Step 4: TRICARE director review
After a formal hearing, you can appeal to the Director of TRICARE. This is the final administrative level.
Step 5: Federal court
If all administrative remedies are exhausted, you may petition a federal district court. This step requires legal representation and is rarely taken.
Expedited appeals
For urgent or ongoing care denials (continuing treatment is at risk), you can request an expedited reconsideration with a 3-day decision window.
Patient advocates
Contact your installation's Patient Advocate or Beneficiary Counseling and Assistance Coordinator (BCAC) at your MTF for free appeal assistance.
Referrals and appeals · Point-of-service
Point-of-service option
The point-of-service (POS) option is what happens when a TRICARE Prime enrollee gets care from a non-network provider without a referral. It is intentionally expensive to discourage bypassing your PCM. Use it only when necessary.
When POS applies
You are enrolled in Prime and you see a TRICARE-authorized (but non-network) provider without a referral from your PCM. This is a choice; you are bypassing the Prime care model.
What POS costs
You pay a POS deductible ($300 individual, $600 family per year in 2026). Then you pay 50% of TRICARE-allowed charges for the rest of the year after the deductible is met.
POS does not apply in emergencies
Emergency care at any provider is covered at normal TRICARE rates regardless of network status. The emergency exception specifically removes POS charges.
Compare POS to Prime rates
A specialist visit on Prime (with referral) might cost $40. The same visit on POS costs 50% of the allowed charge plus the POS deductible. Often ten times more expensive.
When POS is worth considering
Rarely. The main legitimate use case is when you urgently need care from a specific provider who is not in-network and you cannot wait for a referral. Most of the time, the referral process is faster than people expect.
Can you use POS intentionally?
Yes. If you strongly prefer a non-network provider, you can use POS knowingly. Just understand the cost structure going in.
Life changes · PCS
PCS move
A permanent change of station (PCS) is a qualifying life event (QLE) that allows you to make TRICARE enrollment changes outside Open Season. Managing your TRICARE transition correctly prevents coverage gaps during moves.
1
Update DEERS immediately upon PCS orders
Your new installation will need your updated address and unit. DEERS update triggers the PCS QLE window. Do this before or immediately upon arrival.
2
Switch to the TRICARE plan available at your new location
Not all Prime service areas cover all installations. If you move outside a Prime service area, you must switch to Select. Do this at milConnect or by calling TRICARE.
3
Re-establish primary care at the new location
Your PCM assignment may not automatically transfer. Request a new PCM assignment through your regional contractor. For on-installation families, the MTF is the likely assignment.
4
Transfer prescription records
Contact Express Scripts or your retail pharmacy to transfer your prescription history to a pharmacy near your new installation.
5
Verify dependent enrollment in DEERS
PCS moves can occasionally cause errors in dependent records. Confirm all family members are correctly showing at the new installation in DEERS before your first medical appointment.
You have 90 days from a PCS to make enrollment changes
This is your QLE window. Changes made within 90 days take effect prospectively. Do not wait until the last minute.
Life changes · Retiring
Retirement transition
Transitioning from active duty to retirement changes your TRICARE category, your costs, and potentially your plan options. Planning ahead prevents coverage gaps on the day you retire.
1
Attend the pre-separation briefing
Your installation's Transition Assistance Program (TAP) includes a TRICARE briefing. This explains your options, enrollment windows, and what changes on day one of retirement.
2
Choose your retiree plan during the transition window
You have 90 days from retirement to enroll in a retiree plan (Prime or Select) without penalty. Your active duty Prime coverage ends on the day of retirement.
3
Understand the cost change
As an active duty family, you paid $0 enrollment and minimal copays. As a retiree, you will pay enrollment fees and higher copays. Budget for this before it hits.
4
At age 65: transition to TRICARE For Life
When you and your spouse become Medicare-eligible, enroll in Medicare Part B and you automatically qualify for TFL. Do not drop Medicare Part B for any reason.
5
For Reserve/Guard members
At age 60 (or earlier for qualifying reserve retirement points), you transition from TRICARE Reserve Select (or no TRICARE) to regular retiree TRICARE. Plan enrollment in advance.
There is no grace period for TRICARE on the day you retire
Coverage switches exactly on your retirement date. Ensure enrollment paperwork is submitted before that day.
Life changes · Open Season
Open Season
TRICARE Open Season runs from November 10 to December 9 each year. It is the annual window to switch between Prime and Select, add or drop dependents without a QLE, and review plan options for the upcoming year.
Who can make changes
Anyone enrolled in or eligible for a TRICARE Prime or Select plan option. Premium-based plan holders (TRS, TRR, TYA) can also make changes.
What you can change
Plan type (Prime to Select or vice versa), coverage type (individual to family or Self Plus One), regional contractor if multiple are available in your area.
When changes take effect
Enrollment changes made during Open Season take effect January 1 of the following year.
If you do nothing
Your current plan rolls over automatically unless it is discontinued. If your plan terminates, you will receive notice and must select a new plan.
Qualifying life events (QLEs)
Outside Open Season, you can make changes within 90 days of a qualifying event: PCS move, marriage, birth or adoption, loss of other coverage, sponsor change in status.
How to make changes
Online at milConnect (milconnect.dmdc.osd.mil), at your installation's TRICARE Service Center, or by calling 1-800-444-5445.
Review your plan every Open Season even if you are not planning to switch
Provider networks change, copays change, and a plan that was right two years ago may no longer be optimal.
Life changes · Aging off
Aging off TRICARE
Dependent children lose standard TRICARE coverage at age 21 (or 23 if a full-time student). TRICARE Young Adult (TYA) can extend coverage to age 26 at a monthly premium.
When standard dependent coverage ends
At age 21 for non-students. At age 23 for full-time students (with documentation on file in DEERS). The cutoff is the child's birthday.
TRICARE Young Adult (TYA)
Available to adult children up to age 26 who do not have other employer-sponsored coverage. Must be enrolled by the sponsor or the young adult themselves. Premium-based: $794/month (Prime) or $363/month (Select) in 2026.
TYA enrollment
Enroll at milConnect or by calling TRICARE. Coverage can start on the birthday when standard coverage ends, with no gap, if enrolled on time.
No employer coverage requirement for TYA
Unlike ACA parent coverage (which requires no employer coverage), TYA requires the young adult to not be eligible for employer coverage. If they get a job with benefits, TYA eligibility ends.
After age 26
TYA ends. The young adult must obtain individual coverage through an employer, the ACA marketplace, or another source. They are no longer eligible for any TRICARE coverage.
Disabled adult dependents
Qualifying disabled dependents who became disabled before age 21 may remain eligible for standard TRICARE coverage beyond age 21. Document the disability in DEERS.
Life changes · Losing coverage
Losing TRICARE eligibility
TRICARE eligibility can end for several reasons: divorce, discharge, aging off, or loss of sponsor eligibility. Knowing your options before eligibility ends prevents gaps in coverage.
Divorce from sponsor
If you are a former spouse, you lose TRICARE on the date the divorce is final unless you meet the 20/20/20 rule (both you and the sponsor served at least 20 years active duty, and were married for at least 20 years overlapping with service). Otherwise, look into CHCBP.
Discharge of sponsor (non-retirement)
Dependents have Transitional Assistance Management Program (TAMP) coverage for 180 days post-discharge. Then coverage ends. Plan ahead for marketplace or employer coverage.
Continued Health Care Benefit Program (CHCBP)
A premium-based program providing temporary TRICARE-like coverage for those who lose eligibility. Must enroll within 60 days of losing eligibility. 2026 quarterly premium: $2,103 individual, $5,339 family. Maximum 18-36 months depending on category.
Losing TRS or TYA
Involuntary loss of Reserve membership or loss of employment triggers a 90-day QLE window for ACA Special Enrollment. Voluntary disenrollment from TRS does not trigger SEP.
ACA marketplace
If you lose TRICARE, you qualify for a Special Enrollment Period on the ACA marketplace. You have 60 days from loss of coverage. Subsidies may be available.
Cross-cutting questions that span more than one topic. Tap any to see the answer.
Prime is HMO-style, Select is PPO-style. The key practical differences:
Prime: You have a primary care manager (PCM) who coordinates your care. Referrals are required for specialists. Lower copays and no deductible. Requires living in a Prime service area. Best for families who want the lowest out-of-pocket cost and are near an MTF.
Select: No PCM, no referrals. You can see any TRICARE-authorized provider directly. Higher cost-sharing but more freedom. Requires meeting a deductible before cost-shares begin. Better for families who prefer provider flexibility or live away from military installations.
Retirees pay enrollment fees for both; the Select fee is lower. Active duty families pay no enrollment fee for either.
No. Active duty service members have full TRICARE coverage at absolutely no cost. No enrollment fee, no copays, no deductible, no cost-share. This applies to the service member only.
Active duty family members also pay no enrollment fee for Prime or Select, but they do have some copays and cost-shares depending on the plan and type of care.
TFL acts as secondary insurance to Medicare. Medicare pays first for Medicare-covered services. TFL then pays most or all of what Medicare does not cover. For most services, your out-of-pocket cost is $0.
The only cost of TFL is the Medicare Part B premium ($202.90/month in 2026). There is no additional TRICARE enrollment fee.
Critical warning: If you drop Medicare Part B, you lose TFL. There are no exceptions. Many retirees have made this mistake to save the Part B premium, only to lose far more valuable coverage as a result.
TFL becomes the primary payer when you receive care overseas since Medicare generally does not cover overseas care.
Your group is determined by when your military sponsor first entered service:
Group A: Sponsor entered service before January 1, 2018. Lower enrollment fees, lower deductibles, lower copays, lower catastrophic cap.
Group B: Sponsor entered service on or after January 1, 2018. Slightly higher costs across the board.
The distinction was created by the National Defense Authorization Act to gradually shift more costs to newer military families while protecting those who entered under older benefit expectations.
If you are enrolled in a premium-based plan (TRS, TRR, TYA, CHCBP), you follow Group B cost-sharing regardless of your actual group.
Two windows:
Open Season: November 10 to December 9 each year. Anyone enrolled in or eligible for Prime or Select can switch plans, change coverage types, or make other enrollment changes. Changes take effect January 1.
Qualifying Life Events (QLEs): Outside Open Season, you have 90 days from a QLE to make changes. QLEs include PCS moves, marriage, birth or adoption, divorce, loss of other coverage, sponsor retirement or discharge, aging off dependent coverage.
Changes for most QLEs take effect on the date of the event or the first day of the following month, depending on the change.
Yes. TRICARE covers care outside the U.S. through the TRICARE Overseas Program (TOP).
Active duty members stationed OCONUS are typically enrolled in TRICARE Prime Overseas with an assigned overseas PCM. Family members follow the same coverage.
For retirees living overseas who are not in Prime Overseas, TRICARE Select Overseas applies. You find local providers, pay out of pocket, and submit claims to International SOS for reimbursement.
TFL beneficiaries: TFL is primary payer overseas since Medicare does not cover overseas care. Standard TFL cost-sharing applies.
Emergency care is covered anywhere in the world with no prior authorization. Notify TRICARE within 24 hours of an emergency admission when possible.
Your active duty TRICARE coverage ends on the day you retire. On that day you transition from active duty category to retiree category. The costs change significantly.
You have 90 days from retirement to enroll in a retiree plan (Prime or Select). During this window you can also enroll dependents. Miss it and you may wait until Open Season.
As a retiree you will pay enrollment fees and higher copays. Budget for this transition. Use the pre-separation TRICARE briefing at TAP to understand the exact numbers before you retire.
At age 65, when you become Medicare-eligible, enroll in Medicare Part B and you automatically qualify for TRICARE For Life. Do not drop Medicare Part B at any point after that.
The catastrophic cap is the maximum amount you will pay out of pocket for covered TRICARE services in a calendar year. Once you reach it, TRICARE pays 100% for the rest of the year.
2026 caps: Active duty families $1,000 (Group A) or $1,324 (Group B). Retirees on Prime (Group A) $3,000. Retirees on Select (Group A) $4,381.
Enrollment fees, copays, deductibles, and cost-shares all count toward the cap. Monthly premiums for TRS, TRR, and TYA do not count.
TRICARE For Life beneficiaries: Medicare and TFL together provide excellent catastrophic protection without a separate TFL cap.
A few paths depending on your situation:
On Prime with a network civilian PCM: Call your PCM for an appointment. If the MTF is your PCM and cannot see you in time, they can issue a referral to a civilian provider.
On Prime - urgent needs: Go to a network urgent care center without a referral. Call the TRICARE Nurse Advice Line at 1-800-874-2273 for guidance on urgency level.
On Select: You can go to any TRICARE-authorized provider directly. No referral, no waiting for an MTF appointment.
For specialty care on Prime: Ask your MTF to refer you to a civilian network specialist if the MTF cannot provide that specialty or has long wait times. You should not pay point-of-service rates when the MTF initiates the referral.
The TRICARE Nurse Advice Line is a free, 24/7 phone service staffed by registered nurses. You call it to get help deciding whether you need emergency care, urgent care, or can safely wait for a regular appointment.
Call 1-800-874-2273 anytime. Available in English and Spanish. Also available via LiveChat at tricare.mil.
Useful for: fever decisions, medication questions, injury assessment, behavioral health guidance, and understanding whether a symptom warrants immediate attention.
Using the Nurse Advice Line for non-emergency situations saves you money (urgent care copay instead of ER copay) and saves you time. It is one of the most underused TRICARE benefits.
Data sources & methodology
Federal TRICARE data
Defense Health Agency (DHA) · tricare.mil · TRICARE Policy Manual · TRICARE Operations Manual · 10 U.S.C. Chapter 55 (uniformed services health care) · Department of Defense Instruction 6025.19.
2026 figures
DHA CY2026 cost announcement November 7, 2025 · tricare.mil/Costs/Compare (updated January 2026) · Express Scripts TRICARE pharmacy copays effective January 1, 2026 · Active duty family member pharmacy $0 update effective February 28, 2026.
Free help: TRICARE main line 1-800-444-5445 (24/7) · TRICARE Nurse Advice Line 1-800-874-2273 · DEERS Support Office 1-800-538-9552 · Beneficiary Counseling and Assistance Coordinator (BCAC) at your nearest MTF · Military OneSource 1-800-342-9647.
