Tricare Prime: Receiving Care

Good Afternoon Everyone!

Today we are going over receiving care with Tricare Prime.

As we talked about in the post on PCMs, your primary care and most urgent care will come from your PCM (Primary Care Manager) and they will provide you with any referrals for specialized care.

Emergency Care:
Tricare defines an emergency as "a serious medical condition that the average person would consider to be a threat to life, limb, sight or safety".  In the event that you need to receive emergency care, you do NOT need to contact your PCM before receiving care.  However, you will need to contact them within 24 hours of receiving care.  Examples of emergencies would include no pulse, problems breathing, severe bleeding, broken bone, etc.
Please avoid using the emergency room for non emergency problems.  This can result in longer wait times and higher out of pocket cost to you.

Urgent Care:
Tricare defines urgent care services as "medically necessary services required for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours".  These services do require a referral from your PCM if are unable to see them.  You would need to call your PCM for instructions before receiving care for any urgent situation.  These would include things like minor cuts that are not causing severe bleeding, UTIs, ear infections, rising fevers, migraines, etc.

Routine Care:
Routine care is provided by your PCM.  This includes general office visits  and routine preventative care like physicals or well women appointments.

Specialized Care:
Specialized care is defined as "specialized medical services provided by a physician specialist.  Treatment your PCM cannot provide".  Your PCM will provide you with a referral to another health care provider for this specialized treatment.  Examples of this would be a an OBGYN, cardiologist, dermatology, etc.

Tricare has access standards in place to make sure you receive timely care.  These are as follows:

  • Wait time for urgent care should not be more than 24 hours
  • Wait time for a general appointment should not exceed 7 days
  • Wait time for a specialty appointment should not exceed 4 weeks
  • Travel time for routine appointment should not exceed 30 minutes
  • Travel time for specialty care should not exceed 1 hour
These standards may need to be waived if you live more than 30 minutes from the military hospital, clinic or civilian PCM where you want to enroll.  This should be explained when you select your PCM and more information is available online or over the phone with your regional provider.

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Until next time!