FAQs about Tricare Prime Urgent Care Pilot Program for U.S. Military

This week, Tricare Prime launched its new urgent care pilot program offering two visits each fiscal year to some beneficiaries without the requirement for pre-authorization or a referral from a primary care manager.

We’ve compiled this Frequently Asked Questions document to help urgent care centers better understand the program catering to U.S. Military members, veterans, and their families.

Which military members does this apply to?

Most active duty members are covered by Tricare Prime, unfortunately they are excluded from this pilot program expanding access to urgent care. Thus, the program applies only to veterans (not active duty) who’ve opted to pay for the upgrade to Tricare Prime and family members of active duty service members. The pilot program runs through May 23, 2019.

How does an urgent care center know if the patient is covered by Tricare Prime?

U.S. Military healthcare cards do not specify Tricare Prime coverage, so urgent care center staff must verify eligibility for the patient through the military’s website or by calling the Department of Veterans Affairs.

Are there any restrictions in the program?

Tricare Prime beneficiaries can visit urgent care twice in a fiscal year without pre-approval or referral from their primary care manager, but the program requires follow up after such visits. Patients must notify their primary care manager within 24 hours or the first business day after the urgent care visit. This is the same policy that’s been in place for beneficiaries and the authorization requirements have not changed for follow-up care, specialty care, or inpatient care.

What cost responsibility is there for patients?

There is no Point of Service (POS) deductible or cost share for the urgent care visits, but network copayments still apply.

Why is the program launching?

The government is trying to ensure, especially in medically underserved areas of the country, that Tricare beneficiaries can access urgent care without having to travel more than 30 minutes. The Veterans Affairs healthcare system continues to struggle with long wait times. Investigations this year show wait times exceeding 30 days in hundreds of thousands of instances, even after the federal government took aggressive steps in recent years to hire additional staff and expand access.

What if I still have questions about coverage?

Call the VA’s Nurse Advice Line at 1-800-TRICARE (1-800-874-2273), option 1. If the Nurse Advice Line recommends an urgent care visit and a referral is submitted, the visit will not count against the two visits allowed through the pilot program. However, if you are enrolled to a military hospital or clinic and there are appointments available or the facility has an urgent care clinic, and you choose to go to a civilian urgent care clinic that visit will count against your two covered visits per year.