TRICARE Prime covers medically necessary care across a broad set of categories: hospitalization and surgery, preventive services, mental health and substance use treatment, maternity care, laboratory and imaging services, physical and occupational therapy, durable medical equipment, skilled nursing and hospice, autism services, virtual visits, emergency and urgent care, and prescription drugs. Active duty members pay nothing for covered services. Family members and retirees pay set copayments when they follow the plan’s referral rules, and several common needs, including routine dental, eyeglasses, and long-term care, sit outside the benefit entirely.
What TRICARE Prime pays for turns on two ideas. First, the service has to be medically necessary, meaning appropriate, reasonable, and adequate for the condition and a proven treatment. Second, care outside the primary care manager’s office usually needs a referral. Skip the referral and the point-of-service option kicks in, which means a separate $300 individual or $600 family deductible plus higher cost-sharing. Active duty members cannot use point-of-service at all and need a referral for any civilian care outside emergencies.
Preventive Care
Preventive services carry no out-of-pocket cost under TRICARE Prime when obtained from a PCM or network provider, and no referral is required. Covered services include annual physicals, immunizations, well-child exams, and well-woman exams that take in breast exams, pelvic exams, Pap tests, and mammograms. Cancer screenings like colonoscopies are covered, along with cholesterol testing, blood pressure checks, hepatitis B and C screenings, hearing and vision screenings, and tobacco cessation counseling.
Hospital, Surgical, and Diagnostic Care
Inpatient hospital care is covered, including the initial admission, subsequent visits, semiprivate rooms, nursing, meals, anesthesia, lab tests, X-rays, drugs, blood products, and medical supplies. Surgical procedures are covered when medically necessary. Inpatient admissions require pre-authorization.
Lab work and imaging are covered when medically necessary or as part of preventive screening. That includes blood tests, cholesterol panels, MRIs, CT scans, X-rays, and bone density studies. Some specialized imaging may require a referral. Results from military facilities are accessible through the MHS GENESIS patient portal.
Mental Health and Substance Use Treatment
Outpatient mental health visits with a network provider do not require a referral. Covered levels of care include individual, family, and group therapy in an office setting, intensive outpatient programs, partial hospitalization, psychiatric residential treatment for children and adolescents, and inpatient hospitalization. Telehealth-delivered mental health care is also covered.
Substance use disorder treatment is covered at every level, from outpatient counseling through inpatient detoxification and residential programs. Medication-assisted treatment for opioid use disorder is included. Coverage runs on medical necessity, and TRICARE does not impose a hard session limit on outpatient mental health or substance use treatment.
Maternity Care
TRICARE Prime covers all medically necessary pregnancy care. That means prenatal visits from confirmation through delivery, labor and delivery with anesthesia and fetal monitoring, and postpartum care for up to six weeks after birth. Cesarean sections are covered when medically necessary. Hospital stays are covered for a minimum of 48 hours after a vaginal delivery and 96 hours after a C-section. Ultrasounds are covered for specific clinical reasons but not for routine screening or sex determination. Prime enrollees need a referral from their PCM before beginning obstetric care.
Therapy, Equipment, and Extended Care
Physical therapy and occupational therapy are covered when medically necessary and when the patient is making progress. There is no hard visit limit. Under TRICARE Prime, physical therapy costs nothing with a PCM referral, though authorization may be needed after the initial evaluation. TRICARE does not cover maintenance therapy, general exercise programs, chiropractic care, or acupuncture as part of physical therapy.
Medically necessary durable medical equipment is covered, including wheelchairs, oxygen equipment, and hospital beds. The regional contractor decides whether equipment is rented or purchased. Repairs, medically necessary customizations, and replacements due to changes in condition or irreparable damage are covered. Prosthetic devices, including FDA-approved surgical implants, are covered along with training, accessories, and maintenance. DME and custom orthotics require prior authorization.
Hearing aids are covered for active duty members and family members who meet specific hearing-loss thresholds. For adults, that generally means a hearing level of at least 40 decibels at certain frequencies, or a speech recognition score below 94%. Children must meet a 26-decibel threshold. TRICARE does not cover hearing aids for retirees, though retirees may access them through the VA or the Retiree-At-Cost Hearing Aid Program at military facilities.
Skilled nursing facility care is covered with no day limit, provided the patient was hospitalized for at least three consecutive days and enters the facility within 30 days of discharge. Pre-authorization is required. Covered services include semiprivate rooms, nursing, meals, therapy, drugs, and medical supplies.
Hospice care is covered at four levels: routine home care, continuous home care, general inpatient care, and inpatient respite care. The first two benefit periods run 90 days each, followed by unlimited 60-day extensions, all requiring pre-authorization and recertification of the terminal diagnosis. Home health care also requires pre-authorization.
Autism Services
Applied Behavior Analysis for children with autism spectrum disorder is covered through the Autism Care Demonstration, a program authorized through December 31, 2028. There are no yearly or lifetime caps on ABA coverage. Pre-authorization is required, and the initial authorization covers six months of services with renewals every six months. An Autism Services Navigator is assigned to coordinate care for most stateside families.
Virtual Care
TRICARE Prime covers virtual visits for primary care, preventive care, mental health, specialty care, and remote monitoring of chronic conditions. Costs and referral requirements are the same as for in-person visits. The Military Health System Nurse Advice Line is available around the clock for phone, web chat, and video consultations, and select military facilities offer appointment-free virtual urgent care through Quick Care Connect.
Prescription Drugs
Prescriptions are organized into three tiers on the Department of Defense formulary: generic, brand-name, and non-formulary. Cost depends on where the prescription is filled. Military pharmacies fill a supply of up to 90 days at $0 for all tiers. Home delivery, also up to 90 days, runs $14 generic, $44 brand-name, and $85 non-formulary. Retail network pharmacies, up to 30 days, run $16 generic, $48 brand-name, and $85 non-formulary.
Active duty service members pay $0 at all locations. As of February 28, 2026, active duty family members enrolled in TRICARE Prime Remote also pay nothing for covered prescriptions through home delivery and retail network pharmacies.
Some medications require prior authorization, particularly brand-name drugs with generic alternatives, drugs with age limits, or prescriptions exceeding normal quantity limits. Non-covered medications include over-the-counter products (with exceptions for insulin and smoking-cessation aids), homeopathic and herbal preparations, cosmetic drugs, and most multivitamins. Prenatal vitamins with a prescription are covered. Payments for non-covered drugs do not count toward the catastrophic cap.
Emergency and Urgent Care
TRICARE Prime covers emergency care anywhere in the world with no referral or pre-authorization required. After emergency treatment, enrollees must contact their PCM within 24 hours or the next business day, and any follow-up specialty care needs a referral to avoid point-of-service charges.
For urgent care below the emergency threshold, active duty members must go to a military facility or get a referral through the MHS Nurse Advice Line. All other Prime enrollees can visit any TRICARE-authorized urgent care center or network provider without a referral. Going to a non-network provider outside an authorized urgent care center triggers point-of-service fees.
What TRICARE Prime Does Not Cover
The exclusions list is long. Among the items beneficiaries most often ask about:
- Routine dental care. Cleanings, fillings, orthodontics, and oral surgery fall under the separate Active Duty Dental Program or TRICARE Dental Program. Retirees may access dental coverage through FEDVIP. TRICARE’s medical benefit covers only adjunctive dental care tied to a medical condition.
- Eyeglasses and contact lenses. TRICARE covers routine eye exams (annually for active duty families, every two years for retirees on Prime) and medical eye care, but glasses and contacts generally require supplemental FEDVIP vision coverage.
- Long-term care and assisted living.
- LASIK and cosmetic surgery.
- Acupuncture, massage therapy, and chiropractic services.
- Non-surgical weight loss programs and nutrition counseling. Bariatric surgery is covered for patients who meet BMI and medical criteria.
- Experimental or unproven procedures.
- Exercise equipment, gym memberships, and general exercise programs.
How Referrals Shape What Gets Covered
Every TRICARE Prime enrollee is assigned a primary care manager, either a military provider at a base clinic or hospital or a civilian network provider. The PCM handles routine care, preventive visits, and non-emergency needs. When the PCM cannot provide the care a patient needs, the PCM issues a referral to a specialist. The regional contractor then pre-authorizes the appointment and sends a notification letter with the approved provider’s name and an expiration date. Specialty appointments are generally expected within 28 days of the referral.
Referrals are not required for preventive services, outpatient mental health visits with a network provider, or emergency care. For nearly everything else on the covered list, the referral is the difference between a modest copay and paying the point-of-service deductible on top of higher cost-sharing.