POS applies when a TRICARE Prime beneficiary:
- Receives care from a network or non-network TRICARE-authorized provider without a referral from his or her Primary Care Manager (PCM)
- Receives care for clinical preventive services when they see a non-network provider
- Self-refers to a civilian specialty care provider after a referral has been authorized to a military hospital or clinic (MTF) specialty care provider
- Self-refers to a non-network specialty care provider after a referral has been authorized to a network specialty care provider
Using the POS option results in greater out-of-pocket expenses for beneficiaries:
- Annual deductible (applies to outpatient services only): $300/individual and $600/family
- Outpatient cost-share: 50% cost-share of the TRICARE-allowable amount after the annual deductible is met (beneficiary may be responsible for up to 15% above the TRICARE-allowed amount for a non-network provider)
- Outpatient cost-share: 50% cost-share of the TRICARE-allowable amount (beneficiary may be responsible for up to 15% above the TRICARE-allowed amount for a non-network provider)
POS does not apply for services that do not require a referral such as:
- Emergency services
- Preventive care from a network provider
- Beneficiaries whose OHI is primary
- Newborn or adoptee care (a newborn or adoptee is covered as a TRICARE Prime/TRICARE Prime Remote Active Duty Family Member (TPRADFM) beneficiary for the first 90 days after birth or adoption, as long as one additional family member is enrolled in TRICARE Prime/TPRADFM or the sponsor is active duty)
- Active Duty Service Member (ADSM) care (ADSMs who do not coordinate care through their PCM may be responsible for the entire cost of care)
- Ancillary services such as diagnostic radiology and ultrasound services, diagnostic nuclear medicine services, pathology and laboratory services, or cardiovascular studies (unless part of an episode of care that meets the POS requirements as listed above)
