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.
The Urgent Care Pilot Program, scheduled to begin spring 2016, is for:
• 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
• 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 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 pre-authorized visits allowed under the Urgent Care Pilot. However, if you call the NAL and get a referral to a military hospital or clinic and you go elsewhere for care, that visit will count against your two preauthorized visits.
If you need more information, please visit the Urgent Care Pilot Program web page on the TRICARE website.
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