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TRICARE Health Services: Coverage, Costs & Referrals

A guide to TRICARE health services in 2026, covering primary care, specialty referrals, mental health, and emergency costs across East and West regions.

TRICARE Health Services: Coverage, Costs & Referrals

*TRICARE.Com is an independent reference site and is not affiliated with the Department of Defense or the official TRICARE program. For official policy and the most current data, visit TRICARE.mil.*

## Quick answer TRICARE health services cover a vast range of medically necessary care, including preventive screenings, outpatient doctor visits, inpatient hospital stays, and mental health services. Most care is delivered through a network of military hospitals (Direct Care) or civilian providers (Purchased Care) managed by Humana Military in the East and TriWest Healthcare Alliance in the West.

In detail

TRICARE's health services are divided into functional categories. To be covered, a service must be "medically necessary and appropriate."

### Primary & Specialty Care Most beneficiaries start with primary care. Under **TRICARE Prime**, you are assigned a Primary Care Manager (PCM) who coordinates all health services. Under **TRICARE Select**, you can visit any TRICARE-authorized provider without a referral, though your out-of-pocket costs will be lower if you use a network provider.

* **Preventive Services:** Includes annual wellness exams, immunizations, and cancer screenings (e.g., mammograms, colonoscopies). These typically have a $0 copay for all plans. * **Specialty care:** Requires a referral from your PCM if you are on a Prime plan. Select users do not need referrals.

### Behavioral & Mental Health TRICARE provides comprehensive mental health services, including: * Inpatient psychiatric care. * Outpatient psychotherapy (individual, family, group). * Substance use disorder treatment (detoxification and rehabilitation). * **2026 Policy Note:** Most outpatient mental health visits do not require a referral for active duty family members or retirees, though authorization may be needed for intensive programs.

### Hospitalization & Emergency Services * **Emergency Care:** If you have a threat to life, limb, or sight, go to the nearest ER. You do not need prior authorization. * **Urgent Care:** TRICARE Prime beneficiaries (excluding Active Duty Service Members) usually get two unreferred urgent care visits per year, but policies vary; checking with your regional contractor (Humana or TriWest) is recommended. * **Inpatient Stays:** Covered for medical and surgical needs. Costs depend on your "Group" (Group A joined before 2018; Group B joined after).

### 2026 Cost Example (Outpatient Visits) | Plan Type | Active Duty Family (Group A) | Retirees (Group A) | | :--- | :--- | :--- | | **TRICARE Prime** | $0 copay | ~$25–$30 per visit | | **TRICARE Select (Network)** | ~$30–$40 per visit | ~$40–$55 per visit | | **TRICARE Select (Non-Network)** | 20% of allowable charge | 25% of allowable charge |

*Note: 2026 rates are subject to final adjustment by the Defense Health Agency; check official tables for exact cent amounts.*

### Pharmacy & Ancillary Services Managed by **Express Scripts**, the pharmacy benefit includes home delivery, retail network pharmacies, and military pharmacies. Ancillary services like lab work and X-rays are covered when ordered by an authorized provider.

## Who this applies to * **Active Duty Service Members (ADSMs):** Must use TRICARE Prime; all health services are covered with $0 out-of-pocket costs. * **Active Duty Family Members (ADFMs):** Can choose Prime ($0 enrollment) or Select (no enrollment fee, but higher per-visit costs). * **Retirees & Families:** Must pay annual enrollment fees for Prime or Select and share the cost of most health services. * **Guard/Reserve:** Eligible for TRICARE Reserve Select (TRS), which functions similarly to the Select plan with monthly premiums.

Common scenarios

**1. The Specialist Referral (Prime)** Jane is an Army spouse in the East Region (Humana Military). She has a skin rash. She visits her PCM ($0 copay), who refers her to a dermatologist. Because she is on Prime and followed the referral process, her specialty visit has a $0 copay (2026 rates).

**2. The Urgent Care Visit (Select)** Mark is a Navy retiree in the West Region (TriWest). He wakes up with a severe ear infection on a Saturday. He goes to a civilian urgent care center in the TriWest network. He does not need a referral. He pays a $25–$35 copay (2026 rates for Group A retirees) and TRICARE covers the rest.

**3. Emergency Surgery** A TRICARE Reserve Select member requires an emergency appendectomy at a civilian hospital. No prior authorization is needed for the emergency. The member pays their deductible (e.g., ~$125–$300 for 2026) and 20% of the TRICARE-allowable charge for the surgery and hospital stay.

## Related terms * **Allowable Charge:** The maximum amount TRICARE will pay for a covered health service. * **Catastrophic Cap:** The most you will pay out-of-pocket for covered health services each calendar year. * **Point-of-Service (POS) Option:** An expensive penalty cost incurred when a Prime enrollee sees a specialist without a referral. * **Medical Necessity:** The standard used to determine if a service is required to diagnose or treat a condition. * **Authorized Provider:** A doctor or hospital that meets TRICARE licensing and certification requirements.

## Sources * **TRICARE.mil Covered Services:** [https://tricare.mil/CoveredServices](https://tricare.mil/CoveredServices) * **Humana Military (East):** [https://www.humanamilitary.com/](https://www.humanamilitary.com/) * **TriWest Healthcare Alliance (West):** [https://www.triwest.com/](https://www.triwest.com/) * **Express Scripts Pharmacy:** [https://militaryrx.express-scripts.com/](https://militaryrx.express-scripts.com/)