§ 1095f. TRICARE program: referrals and preauthorizations under TRICARE Prime

• (a)
  • (1) Except as provided by paragraph (2), a beneficiary enrolled in TRICARE Prime shall be required to obtain a referral for care through a designated primary care manager (or other care coordinator) prior to obtaining care under the TRICARE program.
  • (2) The Secretary may waive the referral requirement in paragraph (1) in such circumstances as the Secretary may establish for purposes of this subsection.
  • (3) The cost-sharing amounts for a beneficiary enrolled in TRICARE Prime who does not obtain a referral for care under paragraph (1) (or a waiver pursuant to paragraph (2) for such care) shall be determined under section 1075a(c) of this title .
• (b) A beneficiary enrolled in TRICARE Prime shall be required to obtain preauthorization only with respect to a referral for the following:
  • (1) Inpatient hospitalization.
  • (2) Inpatient care at a skilled nursing facility.
  • (3) Inpatient care at a rehabilitation facility.
  • (4) Inpatient care at a residential treatment center.
• (c) The Secretary of Defense shall ensure that no contract for managed care support under the TRICARE program includes any requirement that a managed care support contractor require a primary care or specialty care provider to obtain prior authorization before referring a patient to a specialty care provider that is part of the network of health care providers or institutions of the contractor.