Tricare began an Urgent Care pilot program on May 23, 2016, that extends through May 23, 2019. It allows Tricare Prime, Tricare Prime Remote or Tricare Young Adult-Prime members in the United States to visit Urgent Care facilities twice a year without a referral from a primary care manager (PCM).
Previously, these beneficiaries were required to have a referral from a PCM within 24 hours of going to an Urgent Care facility.
The pilot program allows Tricare beneficiaries to make 2 visits to Urgent Care within each fiscal year, which is October 1 through September 30.
You can now seek help from any Tricare authorized provider. An authorized provider is one that is licensed by a state, accredited by a national organization or meets other standards and is certified to provide benefits under Tricare. These providers are categorized as either network or non-network providers.
If you do receive a referral from your PCM, it does not count against the 2 Urgent Care visits that do not require a referral. If the nurse advice line tells you to go to Urgent Care, it also does not count against your 2 visits per fiscal year.
What is Urgent Care?
If you need medical attention within 24 hours and cannot be seen by your PCM in that time, you need Urgent Care. Some examples of why you might need Urgent Care include: treatment for high fevers, sprains such as your wrist, illness that hinders proper breathing (croup), potential concussion from a fall or other urgent matters that do not threaten life, limb or eyesight.
If an injury does threaten life, limb or eyesight, that is considered an emergency. In that case, you would go to an emergency room.
If you are unsure if your illness requires emergency care, urgent care or simply a scheduled appointment with your PCM, you can call the Tricare nurse advice line at 1-800-Tricare. It is available 24 hours a day, 7 days a week.
What type of Urgent Care providers can you see?
You can see both network and non-network Urgent Care providers. Simply make an appointment or walk in to their facility. There are many different types of Urgent Care providers, all of which are approved for you to visit. These include:
- Family practice
- Internal medicine
- General practice
- Urgent Care Clinic/Convenient Care Center
- Physician Assistant
- Nurse Practitioner
- Certified Nurse Midwife
While you are authorized to visit these Urgent Care facilities, you may still have to pay network copayments. Visit the Tricare copayments site to determine if this applies to you. Although you do not need a referral to go to these Urgent Care locations, you still need to inform your PCM about the care you received. You may also need to schedule a follow-up appointment.
Who is eligible for this pilot program?
All active duty service members in Tricare Prime Remote, activated Guard/Reserve members in Prime Remote and all other beneficiaries enrolled in Tricare Prime, Tricare Prime Remote or Tricare Young Adult Prime can take advantage of this pilot program.
If however, the active duty service member, Guard or Reserve member is enrolled in Tricare Prime, they are not eligible. All beneficiaries enrolled in the U.S. Family Health Plan as well as those families enrolled overseas are not eligible. Those traveling in the United States who are enrolled overseas still do not need a referral from their PCM, they simply are not limited to 2 visits to an Urgent Care facility. Any care received overseas does not count as well.
If eligible beneficiaries exceed more than 2 Urgent Care visits within a fiscal year, they will be required to get a referral from their PCM or will be charged a point-of-service fee. You can avoid this fee by calling the nurse line before going to an Urgent Care facility.