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  • US Family Health Plan

Specialty Care

Get to know your benefit levels.

The US Family Health Plan is a managed care program with two benefit levels:

  • Your TRICARE® Prime benefit level
  • The Point-of-Service (POS) option benefit level

When seeking specialty care, the benefit level you use is determined by whether you have an approved referral.

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Specialty Care Point-of-Service Option



Specialty Care

Getting specialty care

Your Primary Care Provider (PCP) manages your routine care and may refer you to a specialist for additional evaluation or treatment.

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Specialty Care | In-Network
  • Your PCP should refer you to a specialist who participates in the US Family Health Plan network.
  • These referrals do not require approval from the health plan.
  • For covered specialty care rendered by participating specialist, you will pay only your standard TRICARE® Prime benefit level cost share, even if the referral is not on file with the health plan.
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Specialty Care | Out-of-Network
When receiving specialty care from out-of-network providers:

  • If you require medically necessary care that is not available within the network, your PCP can request prior authorization for an out-of-network provider from the health plan.
  • The request must be submitted to and approved by the health plan before care is received in order for you to pay your standard TRICARE® Prime cost share.
  • If not approved, or no request for authorization has been submitted, you may still choose to see the non-participating provider using your Point-of-Service (POS) option, which comes at a higher out-of-pocket cost. See the Point-of-Service (POS) Option below.

What you should do

Steps to take when requesting specialty care:

Always ask your PCP for a referral before seeing a specialist.

Use the provider directory to confirm if your specialist is in-network:

Search Provider Directory

Log into your Member Portal to view authorizations, including those for out-of-network care:

Member Portal

The Point-of-Service Option

The Point-of-Service (POS) option allows you the flexibility to choose to see an out-of-network TRICARE®-authorized provider without prior approval. You will incur higher cost shares if you choose to use the Point-of-Service (POS) Option. While this option can give you greater freedom, you should be sure you understand what your out-of-pocket costs will be before seeking care without a health care provider’s referral.

All prior authorization requirements apply when using the POS option.


Using POS with Out-of-Network Providers

When using your POS option with a TRICARE® authorized provider who does not participate in the US Family Health Plan network:

  • You will pay the following deductible(s):
    • $300 Individual
    • $600 Family
  • You will pay 50% coinsurance
  • You are subject to balance billing costs up to 115% of the allowed amount
  • These costs do not apply toward your catastrophic cap, meaning there is no limit to what you may owe




Need help? We're here for you.

Whether you’re exploring plan options or already a US Family Health Plan member, our team is ready to help.

Prospective Members: Call us at 1-877-757-7087
Current Members: Call Member Services at 1-888-674-8734