New Urgent Care Pilot Program for TRICARE Prime Beneficiaries

As a follow-up to the April 15, 2016 NewsBytes story, the Department of Defense (DoD) will be launching an Urgent Care Pilot Program for TRICARE Prime beneficiaries on Monday, May 23, 2016. This program allows Prime enrollees two visits to a network or TRICARE-authorized provider without a referral or prior authorization per year. Eligible TRICARE Prime beneficiaries include:

  • Active Duty Family Members (ADFMs) enrolled in TRICARE Prime or TRICARE Prime Remote;
  • Retirees and their family members who are enrolled in Prime within the 50 United States or the District of Columbia; and
  • ADSMs enrolled in TRICARE Prime Remote and stationed overseas but traveling stateside.

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 make 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 a beneficiary receives urgent care, he or she must notify their 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.

Beneficiaries are encouraged to call the Nurse Advice Line at 1-800-TRICARE, Option 1, during business hours. If the NAL recommends an urgent care visit and a referral is submitted, that visit will not count against the two pre-authorized visits allowed under the Urgent Care Pilot. However, if the NAL refers to a military hospital or clinic and the beneficiary goes elsewhere for care, that visit will count against the two preauthorized visits.

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Disclaimer: The opinions expressed within this article are the views of the writer and do not necessarily reflect the views and opinions of FRA.

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