Prior Authorization: TRICARE Definition & Guide | TRICARE.com

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## Definition Prior authorization is a formal requirement where your doctor must get approval from your TRICARE regional contractor (Humana Military or TriWest) before you receive specific medical services, procedures, or medications.

## What it means in practice In the TRICARE system, prior authorization is a tool used to ensure that a requested treatment is medically necessary, cost-effective, and falls within the scope of your specific plan’s coverage. While most primary care visits do not require this step, more specialized services—such as home health care, certain mental health treatments, non-emergency surgeries, and brand-name medications—almost always do.

If you have a plan like **TRICARE Prime**, your Primary Care Manager (PCM) is responsible for initiating the authorization process. If you are using **TRICARE Select**, you generally have more freedom to choose your doctor, but you (or your provider) are still responsible for ensuring authorization is in place for high-cost services like MRIs or specialty drug therapy. For the 2026 plan year, failing to obtain prior authorization for a service that requires it can lead to a "Point-of-Service" penalty for Prime users, which includes a 50% deduction from the TRICARE-allowable charge.

The process typically begins with your doctor submitting medical records and a justification to the regional contractor: **Humana Military** for the East Region or **TriWest Healthcare Alliance** for the West Region. For pharmacy needs, **Express Scripts** handles authorizations. Once submitted, a decision is usually rendered within 2 to 5 business days, though urgent requests can be processed faster. You can check the status of these requests by logging into your regional contractor’s secure portal.

It is important to note that an "authorization" is different from a "referral." A referral is a request to see a specialist; an authorization is the specific approval for a procedure or high-cost equipment. Always wait for the official authorization letter or digital notification before scheduling your procedure to avoid unexpected out-of-pocket costs.

## Related terms * **Referral:** A request from your primary care manager for you to see a specialist for a specific condition. * **Medical Necessity:** The standard used by TRICARE to determine if a treatment is appropriate, reasonable, and required for your diagnosis. * **Point-of-Service (POS) Option:** A feature of Prime plans that allows you to see non-network doctors without a referral, but results in much higher out-of-pocket costs and deductibles. * **Regional Contractor:** The private company (Humana Military or TriWest) that manages TRICARE benefits and claims for a specific geographic area. * **Non-Availability Statement (NAS):** A certification that specific care cannot be provided at a Military Medical Treatment Facility (MTF), allowing the member to seek care in the civilian sector.

## Sources * TRICARE.mil: Authorizations and Referrals [https://www.tricare.mil/Authorizations](https://www.tricare.mil/Authorizations) * Humana Military: Prior Authorization Requirements [https://www.humanamilitary.com/provider/authorizations](https://www.humanamilitary.com/provider/authorizations) * TriWest Healthcare Alliance: West Region Provider Portal [https://www.triwest.com/en/provider/](https://www.triwest.com/en/provider/)