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Prior approval required for urgent care

TRICARE -- TRICARE Prime beneficiaries enrolled at military treatment facilities are now required to obtain prior approval from their primary care manager before seeking afterhours, out-of-area or urgent care treatment. 

This policy applies to active duty family members, retirees, and family members of retirees. Prior approval is not required for emergencies. Beneficiaries may continue to seek emergency care at the nearest emergency room. 

There is a significant difference between emergency and urgent care. TRICARE defines an emergency as a medical condition, maternity or psychiatric emergency, that would lead a prudent layperson to believe that a serious medical condition existed, or the absence of medical attention would result in a threat to his or her life, limb or eyesight, and requires immediate medical treatment. 

Urgent care is defined as medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately, but requires professional attention and has the potential to develop such a threat if treatment is delayed longer than 24 hours. 

An urgent care condition could be a sprain, sore throat or rising temperature. 

Always contact the primary care manager on call if you need clarification. 

If a beneficiary does not receive prior approval from the PCM for urgent/ nonemergency care obtained while out-of-area or after hours, billing for care will be processed under the point-of-service option, which includes an annual deductible and cost share. 

The annual deductible is $300 per individual or $600 per family. Once the deductible is met, TRICARE will cover only 50 percent of the TRICARE allowable charge. 

In or out of the area, Whiteman beneficiaries can reach their PCM by calling 687-2188 or 1-888-334-2958. 

After hours, beneficiaries will be connected to an answering service that will put them in touch with the on-call PCM. After receiving instructions from their PCM, beneficiaries may call 1-888-TRIWEST to locate a network provider nearby. 

(Information courtesy of TriWest Healthcare Alliance)