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Choosing Care with TRICARE: 2026 Guide

Guide to choosing providers and services under TRICARE, including 2026 cost-shares, referral rules, and regional contractor information for East and West.

Choosing Care with TRICARE: 2026 Guide

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## Quick answer TRICARE covers **Choosing** specialized care, such as health screenings, durable medical equipment (DME), and specialized treatments, provided they are "medically necessary and appropriate." Whether you need a referral to choose your own provider depends on whether you are using a Prime plan (which requires a Primary Care Manager) or a Select plan (which offers more flexibility).

## In detail When choosing healthcare services under TRICARE, your level of freedom and your out-of-pocket costs are determined by your plan type and your beneficiary status (Group A vs. Group B).

### 1. Choosing a Provider: Prime vs. Select * **TRICARE Prime:** You are generally assigned a Primary Care Manager (PCM) at a Military Treatment Facility (MTF) or within the civilian network. To choose a specialist, you must obtain a referral from your PCM. If you choose to see a specialist without a referral, you will be charged under the **Point-of-Service (POS) option**, which includes a $300 deductible and 50% cost-shares (2026 rates). * **TRICARE Select:** This is a PPO-style plan. You have the freedom to choose any TRICARE-authorized provider (Network or Non-Network) without a referral. However, choosing a Network provider results in lower cost-shares.

### 2. Choosing Medical Equipment and Supplies When choosing Durable Medical Equipment (DME), TRICARE requires that the item be: * Ordered by a physician. * Medically necessary (treats a specific illness or injury). * Not "luxe" or purely for convenience (e.g., TRICARE covers basic wheelchairs, but may not cover customized high-end racing models unless medically justified).

### 3. Regional Management Your choice of network providers is managed by one of two regional contractors: * **East Region:** Humana Military. * **West Region:** TriWest Healthcare Alliance (as of the T-5 contract transition on Jan 1, 2025).

### 2. Choosing Preventive Services TRICARE emphasizes preventive care. You can choose to receive many "clinical preventive services" with **$0 out-of-pocket costs** if you use a network provider, including: * Annual wellness exams. * Cancer screenings (Mammograms, Colonoscopies). * Vaccinations and immunizations.

Comparison Table: Cost of Choosing (2026 Rates - Group A Retirees)

| Service Type | TRICARE Prime (Network) | TRICARE Select (Network) | | :--- | :--- | :--- | | **PCP Visit** | $25 | $38 | | **Specialist Visit** | $43 | $53 | | **ER Visit** | $78 | $145 | | **Deductible** | None | $190 (Individual) |

## Who this applies to * **Active Duty Service Members (ADSMs):** Must use TRICARE Prime; they have the least "choice" and must follow PCM referrals for all care. * **Active Duty Family Members (ADFMs):** Can choose between Prime (lower cost) or Select (higher choice). * **Retirees and their Families:** Can choose between Prime or Select, though Prime enrollment fees apply ($392.04/individual for 2026). * **TRICARE Reserve Select (TRS) Members:** Use a plan similar to Select, allowing them to choose any authorized provider.

Common scenarios

**Scenario 1: Choosing a Specialist (Prime)** Jane is a retired Navy officer on TRICARE Prime. She wants to see a specific dermatologist. If she gets a referral from her PCM, her 2026 copay is **$43**. If she "chooses" to go without the referral, she triggers the Point-of-Service option and pays 50% of the total bill.

**Scenario 2: Choosing a Specialist (Select)** Mark is an Army spouse on TRICARE Select. He decides to see a network physical therapist. Because he is on Select, he does not need a referral. He simply pays his **$53 specialist copay** (2026 rate for Group A) after meeting his annual deductible.

**Scenario 3: Choosing an Urgent Care Center** Most TRICARE beneficiaries (excluding ADSMs) can choose to visit any **Network Urgent Care center** without a referral. For a Select ADFM in 2026, this visit would typically cost **$31**.

## Related terms * **Medically Necessary:** Healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, or condition. * **Network Provider:** A doctor or facility that has a contract with Humana Military or TriWest to provide care at negotiated rates. * **Point-of-Service (POS) Option:** An expensive cost-sharing trap triggered when Prime members see specialists without a referral. * **Authorization:** A review by the regional contractor (Humana or TriWest) to ensure a "chosen" treatment is covered before it happens. * **Cost-Share:** The percentage of the total bill you pay (common in TRICARE Select).

## Sources * TRICARE.mil - Covered Services: https://www.tricare.mil/CoveredServices * Humana Military (East): https://www.humanamilitary.com/ * TriWest Healthcare Alliance (West): https://www.triwest.com/ * Defense Health Agency - 2026 Costs: https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Cost-Shares