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TRICARE Provider Guide: Network vs. Non-Network Costs

Understand the differences between TRICARE network, non-network, and military providers, including 2026 cost implications and referral rules.

TRICARE Provider Guide: Network vs. Non-Network Costs

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## Quick answer A TRICARE provider is any healthcare professional, clinic, or hospital authorized to provide medical care to military beneficiaries. Your costs and whether you need a referral depend on if the provider is "Network" (contracted with TRICARE), "Non-Network" (participating or non-participating), or a military hospital or clinic.

## In detail Understanding your provider type is the most important factor in determining your out-of-pocket costs and your quality of access. Under the T-5 contract (effective January 2025), your regional contractor manages these provider networks: **Humana Military** in the East Region and **TriWest Healthcare Alliance** in the West Region.

### 1. Military Hospitals and Clinics (MTFs) These are government-run facilities located on military installations. * **Cost:** $0 for almost all beneficiaries. * **Priority:** Active duty service members (ADSMs) have first priority, followed by Active Duty Family Members (ADFMs) enrolled in TRICARE Prime.

### 2. Network Providers These are civilian doctors and hospitals that have signed a contract with Humana Military (East) or TriWest (West). * **Agreement:** They agree to specific reimbursement rates and file all claims for you. * **Costs:** You pay a fixed copayment (e.g., in 2026, a TRICARE Select Group A retiree might pay a $38 copay for a primary care visit). * **Referrals:** Prime enrollees usually need a referral to see a network specialist.

### 3. Non-Network Providers (Two Sub-types) These providers do not have a contract with TRICARE. They fall into two categories:

| Provider Type | What it means for you | Costs (2026 Estimates) | | :--- | :--- | :--- | | **Participating** | They don't have a contract but agree to accept the TRICARE-allowable charge as full payment on a case-by-case basis. | You pay your deductible and a percentage of the allowable charge (cost-share). | | **Non-Participating** | They do not accept the TRICARE-allowable charge. They can charge you up to **15% above** the allowable amount. | You pay your cost-share PLUS the "balance billing" (up to 15% extra). |

### Providers for Specialized Care * **Pharmacy:** Managed by **Express Scripts**. You must use a retail network pharmacy or the Home Delivery service to avoid high non-network costs. * **Overseas:** Managed by **International SOS**. Providers overseas may require upfront payment unless you are an ADSM or have a guarantee of payment.

## Who this applies to * **Active Duty Service Members:** Must use Military Hospitals or Clinics unless they receive a referral to a civilian network provider. * **Active Duty Family Members (Prime):** Generally required to use network providers to maintain the $0 deductible and low/no copays. * **TRICARE Select Beneficiaries:** Have the most flexibility to choose any "authorized" provider (Network or Non-Network), but pay significantly more for using non-network doctors. * **TRICARE For Life (TFL) Users:** Can see any provider who accepts Medicare and TRICARE.

Common scenarios

**Scenario 1: The Network Specialist (TRICARE Prime)** Jane is an ADFM in the West Region (TriWest). Her PCM refers her to a network dermatologist. Because she stayed in the network, her specialist visit in 2026 costs **$0**.

**Scenario 2: The Non-Participating Provider (TRICARE Select)** Mark, a retired veteran, sees a cardiologist who does not participate with TRICARE. The TRICARE-allowable charge is $200. The doctor charges $230 (the 15% maximum overage). Mark pays his 25% cost-share ($50) **plus** the extra $30 balance billing, totaling **$80** for the visit.

**Scenario 3: The Retail Pharmacy (Point of Service)** Sarah takes a maintenance medication. If she uses a network pharmacy like Walgreens, she pays a standard copay (e.g., $16 for brand-name). If she goes to an out-of-network "mom-and-pop" shop that isn't in the Express Scripts network, she may have to pay the **full price** upfront and file for partial reimbursement later.

## Related terms * **Allowable Charge:** The maximum amount TRICARE will pay for a specific medical service. * **Balance Billing:** When a non-participating provider bills you for the difference between their fee and the TRICARE-allowable charge (capped at 15%). * **PCM (Primary Care Manager):** The specific provider (civilian or military) assigned to manage a Prime enrollee’s care. * **Referral:** A request from your PCM for you to see a specialist or different provider. * **Authorized Provider:** A provider who meets the licensing and accreditation standards required by the Defense Health Agency to get paid by TRICARE.

## Sources * TRICARE.mil Provider Types: https://www.tricare.mil/Providers/Types * Humana Military (East Contractor): https://www.humanamilitary.com/ * TriWest Healthcare Alliance (West Contractor): https://www.triwest.com/ * Defense Health Agency Cost Plans: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Cost-and-Billing/Cost-Shares-and-Deductibles