Urgent care facilities treat non-life-threatening conditions that require immediate attention, such as minor sprains, high fevers, or severe sore throats, often when a primary care manager is unavailable. The Tricare system, managed by the Defense Health Agency (DHA), covers urgent care, but the specific coverage varies depending on the health plan a beneficiary is enrolled in.
Tricare Coverage Across Different Plans
Tricare covers urgent care, with the exact coverage mechanism tied directly to the beneficiary’s enrollment plan. Tricare Prime is a managed care option, similar to a health maintenance organization (HMO), where care is coordinated through a Primary Care Manager (PCM). Prime typically offers the lowest out-of-pocket costs for network services but comes with stricter rules for civilian care.
Tricare Select functions more like a preferred provider organization (PPO), offering greater flexibility in choosing providers. Select beneficiaries can access any Tricare-authorized provider for urgent care, whether they are in-network or out-of-network. This broader choice means Select enrollees manage their own care, but it generally results in higher cost-sharing compared to Prime. For all plans, urgent care should be used for acute, non-emergency conditions that need attention within 24 hours, reserving emergency rooms for true life, limb, or eyesight threats.
Understanding Referral Requirements
Accessing urgent care without initial authorization is simpler for most Tricare Prime beneficiaries. Active Duty Family Members and retirees enrolled in Prime generally do not need a referral to visit a Tricare-authorized urgent care center or network provider. This policy change was implemented to improve access to care and encourage the use of appropriate facilities.
Active Duty Service Members (ADSMs) must follow service-specific regulations and should seek care at a Military Hospital or Clinic (MHC) when available. If an ADSM uses civilian urgent care, they are typically required to notify their PCM afterward. Prime beneficiaries who seek urgent care from a non-network provider without authorization will incur higher financial penalties known as Point-of-Service (POS) charges.
Associated Costs and Copayments
The financial structure for urgent care is determined by the beneficiary category, the specific Tricare plan, and the network status of the facility. Active Duty Family Members (ADFMs) enrolled in Prime generally face a $0 copayment for urgent care received at a network provider or authorized urgent care center. This $0 cost structure applies to both Group A (entered service before 2018) and Group B (entered service in 2018 or later) beneficiaries.
Retirees and their family members enrolled in Prime have a small copayment, which is typically around $37 for an urgent care center visit. The cost structure for Tricare Select involves an annual deductible that must be met before cost-sharing begins. After the deductible is satisfied, Select beneficiaries pay a percentage of the Tricare-allowable charge, with higher cost-shares for using out-of-network providers.
Locating Tricare-Approved Urgent Care Facilities
Finding a Tricare-approved urgent care facility is a practical step that can prevent unexpected out-of-pocket charges. Beneficiaries should use the official provider search tools available on the Tricare website or through their regional contractor’s portal. These directories allow a search filter for Tricare-authorized urgent care centers and network providers in a specific geographic area.
It is highly recommended to verify the network status of a facility before receiving care to ensure the visit is processed at the lowest possible cost. A secondary resource is the Military Health System Nurse Advice Line (NAL), which is available 24/7. The NAL can offer medical advice and help locate a nearby Tricare-authorized urgent care provider, simplifying the search process for immediate needs.