From: Syliva Sullivan
CIV, OASD(HA)/TMA

WASHINGTON, D.C. The point-of-service option under TRICARE Prime is one of the least-understood benefits by DoD TRICARE beneficiaries enrolled in the Prime (health-maintenance-organization-like) plan.

Point-of-service means TRICARE Prime enrollees have the freedom to receive services without a referral or authorization. Such unlimited access can be costly, however, as Prime enrollees have to pay significantly higher cost-shares and a deductible, neither of which apply when enrollees use Prime network primary care managers (PCMs) to coordinate all their non-emergency care.

By choosing and using a PCM for all non-emergency care, enrollees have much lower out-of-pocket costs. Network PCMs determine when access to specialty care is medically necessary, and when it is, they make the referral. After a referral is made, TRICARE's health care finders give out the referral information. When patients bypass their PCMs and seek care without a referral, they should be aware of the following:

1. Care must be medically necessary and obtained from authorized providers, or TRICARE will pay nothing;

2. The beneficiary will be responsible for an annual deductible of $300per individual or $600 for a family. This deductible applies to both inpatient and outpatient services and is applied on an enrollment-year basis;

3. After the deductible is met, the enrollee is responsible for 50percent of the TRICARE allowable charges. The TRICARE allowable charge is the amount a provider can charge for a specific service. The charge depends on the service provided;

4. If care is sought at a non-network provider, the provider may charge the patient even more-up to 15 percent above the TRICARE allowable charge;

5. The point-of-service option does not apply to emergency care. Enrollees should review and understand the definition of emergency care in the TRICARE Prime handbook;

6. Charges paid with the point-of-service option do not apply to the catastrophic cap (including deductibles and cost-shares).

TRICARE Prime was designed to involve very little paper work, low out-of-pocket costs, and to ensure that an enrollee's care is coordinated. In addition, Prime encourages enrollees to actively participate in their own health care and health promotion. TRICARE beneficiaries need to consider what they want in regard to unlimited versus limited access to providers and the price they are willing to pay. Only then can they make their decisions accordingly. It is nice to know enrollees may visit any provider they choose, but they must understand the costs involved in making this decision.

For more information, Prime enrollees should visit or call their TRICARE service center or visit the TRICARE Website

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