The National Defense Authorization Act (FY16), Section 725 directed the DOD to conduct a three-year Urgent Care Pilot Program. The pilot lets Prime enrollees get urgent care without an authorization and will help DOD decide if not requiring urgent care authorizations will:

• Improve access to urgent care

• Encourage enrollees to use less intensive resources (i.e., go to an urgent care center instead of an emergency room)

• Increase enrollee satisfaction

1. What is the Urgent Care Pilot Program?

A three-year program that lets most Prime enrollees get two urgent care visits per fiscal year per enrollee without a referral and authorization.

2. When does the Urgent Care Pilot Program start?

May 23, 2016

3. Who can participate in the Urgent Care Pilot Program?

• TRICARE Prime enrollees (except active duty service members)

• TRICARE Prime Remote enrollees (including active duty service members)

• TRICARE Young Adult-Prime enrollees

• TRICARE Prime Overseas and TRICARE Prime Remote Overseas enrollees but only when traveling stateside (there’s no limit to the number of unauthorized urgent care visits)

4. What should I do if I’m not sure if I need urgent care?

Urgent care services are medically necessary services which are required for illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have the potential to develop such a threat if treatment is delayed longer than 24 hours. If you live in the U.S., call the Nurse Advice Line at 1-800-874-2273. The Nurse Advice Line will answer your urgent care questions and give you health care advice

5. What happens if I get more than two unauthorized urgent care visits in a fiscal year?

After the second unauthorized urgent care visit, you will pay the point-of-service deductible and cost shares. After the second unauthorized visit you must obtain a referral within three business days of your urgent care visit in order to avoid point-of-service charges. Naval Health Clinic Patuxent River will not initiate a backdated referral to cover services rendered without obtaining a referral within the three business days.

6. I’m an active duty service member enrolled in TRICARE Prime. Can I get unauthorized urgent care visits?

No. ADSMs enrolled in Prime can’t participate in the pilot. You have to get a referral and prior authorization to get care from someone other than your PCM.

7. I’m an active duty service member enrolled in TRICARE Prime Remote. Can I get unauthorized urgent care visits?

Yes. You can get two urgent care visits per fiscal year.

8. I used both of my unauthorized urgent care visits. The urgent care clinic told me to come back in three days for follow-up care. Will the pilot cover my follow-up visit without a referral and authorization?

No. You need to contact your PCM to schedule a visit or get a referral and authorization for follow-up care with the urgent care facility. If you don’t get a referral and authorization prior to your follow up urgent care visit, you’ll pay the point-of-service deductible and cost-share.

9. If I call the Nurse Advice line and get a referral, does that count against my two unauthorized visits under the pilot?

No.

For additional information please visit: http://www.tricare.mil/Plans/SpecialPrograms/UrgentCarePilot.aspx