New Urgent Care Pilot Program for Prime Beneficiaries
To increase access to care, the Department of Defense is launching an Urgent Care Pilot Program for TRICARE Prime beneficiaries. This program allows Prime enrollees two visits to a network or TRICARE-authorized provider without a referral or prior authorization.
For a list of all the provider types you can see, visit the TRICARE website. While TRICARE encourages the use of network providers, you may also see non-network providers as long as they are TRICARE-authorized. Visits to providers who are not one of the provider types listed are not covered under this pilot.
The Urgent Care Pilot Program, scheduled to begin May 23, 2016, is for:
- Active duty service members (ADSMs) (including National Guard or Reserve members activated for more than 30 consecutive days) in TRICARE Prime Remote
- Non-ADSMs in TRICARE Prime, TRICARE Prime Remote or TRICARE Young Adult Prime
- TRICARE Overseas Program beneficiaries traveling in the U.S. (not limited to two visits)
Active Duty Service Members (ADSMs) enrolled in TRICARE Prime are not eligible for this program as their care is managed by their Service. This pilot also excludes Uniformed Services Family Health Plan (USFHP) enrollees. TRICARE Overseas Program (TOP) enrollees can receive an unlimited number of urgent care visits, but only when they are traveling stateside and seeking care.
There are no Point of Service (POS) deductibles or cost shares for these two urgent care visits, but network copayments still apply.
Once you receive urgent care, you must notify your PCM about that care within 24 hours or the first business day after the urgent care visit. Authorization requirements have not changed for follow up care, specialty care or inpatient care.
When you are not sure of the type of care you need, or you require care outside of standard business hours, call the Nurse Advice Line (NAL). If the NAL recommends an urgent care visit, and a referral is submitted, that visit will not count against the two visits allowed under the Urgent Care Pilot. However, if you are enrolled to a military hospital or clinic and there are appointments available or the facility has an available urgent care clinic and you choose to go to civilian urgent care clinic, that visit will count against your two covered visits per year.