Urgent Care Pilot Program

Are you enrolled in TRICARE Prime, TRICARE Prime Remote or TRICARE Young Adult-Prime in the United States?

If so, you may be able to participate in the new Urgent Care Pilot Program.

What is the Urgent Care Pilot Program?

When enrolled in a Prime plan, you usually have two options for getting urgent care:

• Get urgent care from your primary care manager (PCM), or
• Get a referral from your PCM to get urgent care from a different provider

With the Urgent Care Pilot Program, we'll cover two urgent care visits each fiscal yearOctober 1 - September 30 where:

• You don't need a referral or authorization from your PCM.
• You can visit any TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. with a primary care specialty.

This means you can get urgent care twice (per fiscal year) from a provider other than your PCM without a referral from your PCM. The pilot begins on May 23, 2016 and will end May 23, 2019.

What is Urgent Care?

Urgent care is care you need for a non-emergency illness or injury. You need urgent care treatment within 24 hours, and you shouldn’t have to travel more than 30 minutes for the care. You typically need urgent care to treat a condition that:

• Doesn’t threaten life, limb, or eyesight.
• Needs attention before it becomes a serious risk to your health.

Examples may include things like a high fever or sprained ankle. Urgent care is different than emergency care.

Not sure if you need urgent care? Please call the Nurse Advice Line:

• 1-800-TRICARE (1-800-874-2273), option 1
• 24 hours a day, 7 days a week

Please note: If you're enrolled at military hospital or clinic and receive pre-authorization from the Nurse Advice Line for urgent care, or your PCM submits a referral for urgent care, it won't count against your two visits. If you're enrolled to a civilian PCM and your PCM submits a referral for urgent care, it won't count against your two visits.

Am I eligible?

The Urgent Care Pilot Program is available to:

• Active duty service members enrolled in TRICARE Prime Remote
• ActivatedCalled or ordered to active duty service for more than 30 days in a row. Guard/Reserve members enrolled in TRICARE Prime Remote
• All other beneficiaries enrolled in TRICARE Prime, TRICARE Prime Remote, or TRICARE Young Adult-Prime

The Urgent Care Pilot Program is not available to:

• Active duty service members enrolled in TRICARE Prime
• Activated Guard/Reserve members enrolled in TRICARE Prime
• Beneficiaries enrolled in the US Family Health Plan
• Beneficiaries enrolled overseas*

*While traveling in the U.S., you don't need a referral from your PCM and you aren't limited to a two visit limit. The Urgent Care Pilot Program doesn't apply to urgent care you may get overseas.

How does the pilot work?

When you need urgent care:

Schedule an appointment with any TRICARE-authorized provider, network or non-network. You can see the following provider types when getting care under the Urgent Care Pilot:

• Family practice
• Internal medicine
• General practice
• Pediatrician
• Obstetrician/Gynecologist
• Urgent Care Clinic/Convenient Care Center
• Physician Assistant
• Nurse Practitioner
• Certified Nurse Midwife

After your urgent care visit, we encourage you to:

• Notify your PCM about the urgent care visit within 24 hours.
• Get follow-up care from your PCM, if needed.

If you see another provider for urgent care for follow-up care without a referral, it will count against the two visit limit.

What are my costs for the Urgent Care Pilot?

Your costs depend on where you go for urgent care:

• Military hospital or clinic: $0
• TRICARE-authorized provider: >>Prime Copayments Apply

What's Different?

• Before the pilot, if you got urgent care without a referral, you paid point-of-service (POS) fees. 
• Now, you can get two urgent care visits without POS fees or a referral.

What happens after I meet the two visit limit?

After you meet the two visit limit each fiscal year, you must have a referral from your PCM for any urgent care they can’t provide. Without a referral, you’ll be using the point-of-service option. To avoid point-of-service fees: 

• Schedule all urgent care appointments with your PCM, or get a referral from your PCM to see another provider or Urgent Care Center. 
• Call the Nurse Advice Line at 1-800-TRICARE (1-800-874-2273), option 1, 24 hours a day, 7 days a week. 

I'm enrolled overseas and traveling stateside. Do I need a referral from my PCM?

No. You don’t need a referral from your PCM and you aren’t limited to a two visit limit when traveling in the U.S.  You must get the urgent care from a TRICARE authorized provider, network or non-network. The provider must have one of the following primary care specialtiesA branch of medicine or surgery that a doctor specializes in.:

• Family practice
• Internal medicine
• General practice
• Pediatrician
• Obstetrician/Gynecologist
• Urgent Care Clinic/Convenient Care Center
• Physician Assistant
• Nurse Practitioner
• Certified Nurse Midwife