Pilot urgent care program for Prime beneficiaries

FALLS CHURCH, Va. — To increase access to care, the Defense Department 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.

“We’d prefer they call us, but if they’re in a crunch, members can now go to an urgent-care facility twice without a referral and let us know about it afterward so their primary-care manager can follow up with their treatment,” said Lt. Col. Bret LeSuer, chief of medical staff at the 75th Medical Group. “We’d really like to keep members from going to an emergency room, which can cost much more, when they have a condition that can be treated in an urgent-care facility.”

The Urgent Care Pilot Program, scheduled to begin May 23, is for:

• Active-duty service members (ADSMs), including National Guard or Reserve members activated — called or ordered to active-duty service — 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 enrolled in Tricare Prime are not eligible for this program, since 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 deductibles or cost shares for these two urgent care visits, but network copayments still apply.

Once an individual receives urgent care, he or she must notify their primary care manager 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.

Those who are not sure of the type of care they need, or who require care outside of standard business hours, should call the Nurse Advice Line. If the NAL recommends an urgent care visit, and a referral is submitted, that visit will not count against the two preauthorized visits allowed under the Urgent Care Pilot Program. 

However, if an individual calls the NAL and gets a referral to a military hospital or clinic and they go elsewhere for care, that visit will count against the two preauthorized visits.