Under TRICARE Prime, most of your routine health care occurs under the close supervision of your primary care manager (PCM. But in cases of emergency or urgent situations, your PCM may not always be there. TRICARE gives you enough flexibility to be able to receive timely care no matter where you may be. Conditions do apply and you must still communicate with your PCM about what is going on as soon as possible. As a last option, you can also see any authorized TRICARE provider you like, but for higher copayments or coinsurance.
When you need immediate medical attention, that is considered an emergency. Under TRICARE Prime, you can receive emergency care even without first contacting your PCM or TRICARE regional contractor for permission. This is one situation where you do not need to get a referral with Prime.
However you still must let your PCM know either within 24 hours of your receiving care, or on the next business day. This will allow your PCM to coordinate with the provider who has given you emergency care. It also ensures you will be able to get prior authorization for certain services if needed.
An urgent care condition is one that is not immediately life-threatening or gravely serious, but must be treated in 24 hours. Otherwise it could turn into an emergency situation as in the previous section.
If you have an urgent condition, you can contact your Prime PCM and ask for an urgent care appointment on the same day. If you happen to be not at home and it’s too far away to see your PCM, you must still ask your PCM for a referral to another provider, or contact your TRICARE regional contractor for help.
If you don’t coordinate with your PCM, and instead see any provider on your own, your care will be covered by the Point of Service (POS) option, which means a higher cost share for you. WIth POS, you must satisfy a deductible ($300 for one person, $600 for family), and pay a 50% cost share plus up 15% above the TRICARE allowable charges.
POS does not apply to active-duty service members or ADSM, newly born or adopted children for the first 60 days, and those with other health coverage besides Prime.
For Active-Duty Service Members
For any type of care other than emergency care, ADSM’s should always use a military treatment facility (MTF) if one is available. If there is no MTF present where you are at at the time you need care, you will need prior authorization and a referral from your PCM in order to see a civilian provider. Either the civilian provider or you can contact TRICARE for assistance.