TRICARE Referrals & Authorizations: 2026 Guide | TRICARE.com

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## Quick answer A **referral** is a request from your primary doctor to see a specialist, while an **authorization** is a pre-approval from your regional contractor (Humana Military or TriWest) that the service is medically necessary and covered. Most TRICARE Prime users need both for specialty care, while TRICARE Select users typically do not need referrals but may still need authorizations for complex procedures.

Details

Managing care in the TRICARE system requires understanding the distinction between these two clinical "green lights." If you seek care without the required paperwork, TRICARE may deny the claim or apply a "Point of Service" (POS) penalty, which can result in 50% higher out-of-pocket costs.

### What is a Referral? A referral is essentially a "hand-off" from your Primary Care Manager (PCM). * **TRICARE Prime:** You generally must have a referral for any care your PCM cannot provide (e.g., seeing a cardiologist or physical therapist). * **Exceptions:** You do not need a referral for emergency care, urgent care centers (for most Prime beneficiaries), or preventative services like annual checkups and mammograms. * **Military Hospitals:** If you are enrolled at a Military Treatment Facility (MTF), your referral will usually be directed to a specialist within the hospital first before being sent to the civilian network.

### What is a Prior Authorization? An authorization is a legal and financial review. Even if your doctor refers you, the regional contractor (Humana Military in the East or TriWest in the West) must confirm the service is a covered benefit. * **Commonly Authorized Services:** Hospitalizations, weight-loss surgery, home health care, MRI/CT scans (in some regions), and durable medical equipment. * **TRICARE Select:** While you have the freedom to see any TRICARE-authorized specialist without a referral, the contractor may still require "Prior Authorization" for high-cost or complex procedures.

### Regional Management (2026 Data) The contractor responsible for processing your requests depends on your location: * **TRICARE East:** Managed by Humana Military. * **TRICARE West:** Managed by TriWest Healthcare Alliance (as of the T-5 contract transition). * **Overseas:** Managed by International SOS.

### Costs and Penalties (2026 Rates) If you are on TRICARE Prime and see a specialist without a referral, you are using the **Point-of-Service (POS) Option**. In 2026, this results in: * An individual deductible of **$300**. * A family deductible of **$600**. * Cost-shares of **50% of the TRICARE-allowable charge** after the deductible is met. * Note: POS charges do **not** count toward your annual Catastrophic Cap.

## Who this affects * **Active Duty Service Members (ADSMs):** Always require referrals and authorizations for all civilian care to ensure medical readiness. * **Active Duty Family Members (ADFMs):** Required to have referrals if enrolled in Prime; not required for Select. * **Retirees and their Families:** Required to have referrals if enrolled in Prime (where available); not required for Select. * **National Guard and Reserve:** Depends on whether they are using TRICARE Reserve Select (no referrals) or are on active duty orders (referral required).

## Sources * TRICARE.mil: Referrals and Prior Authorizations (https://www.tricare.mil/referrals) * Humana Military (TRICARE East): (https://www.humanamilitary.com) * TriWest Healthcare Alliance (TRICARE West): (https://www.triwest.com) * TRICARE.mil: Point of Service Option (https://tricare.mil/pos)