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 the specialist participates in the US Family Health Plan network.
Benefit Level Overview
Review your benefit level information below.
Getting specialty care
Your Primary Care Provider (PCP) manages your routine care and may refer you to a specialist for additional evaluation or treatment.
Specialty Care | In-Network |
When receiving specialty care from in-network providers:
- 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.
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:
Use the provider directory to confirm if your specialist is in-network:
Log into your Member Portal to view authorizations, including those for out-of-network care:
The Point-of-Service (POS) 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
Have questions? We're here to help.
Call US Family Health Plan Member Services to speak with one of our health plan specialists today. We're here for you!