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News | March 9, 2023

How Does TRICARE Cover Different Types of Care?

By TRICARE Communications

Do you know where to go if you break a bone? What would you do if you had the flu? It’s good to know the general types of health care available to you—especially when you need to make a quick decision about where to get care. And knowing how TRICARE covers each type can help you understand your health plan’s costs and rules for getting care.
 
“The TRICARE plan you use affects the rules you should follow to get different types of care,” said Dr. Stacy Usher, lead nurse of Clinical Oversight and Integration for the TRICARE Health Plan. “For example, if you need emergency care, your plan affects who you need to contact after you leave the emergency room. If you need specialty care, your plan determines when you need to get a referral.”
 
Read on to learn about types of care covered by TRICARE.
 
Emergency Care
Emergency care is for an illness or injury that threatens your life, limb, sight, or safety. Examples of emergencies include broken bones, spinal cord injuries, severe eye injuries, severe bleeding, chest pain, no pulse, and the inability to breathe.
 
If you or a family member has a medical emergency, you should call 911 (or your international emergency number) or go to the nearest emergency room.
 
You don’t need a referral or pre-authorization to seek emergency care. However, if you have a TRICARE Prime plan, you should do the following after receiving emergency care:
  • Contact your primary care manager (PCM) within 24 hours or the next business day.
  • Ask your PCM for a referral if you need specialty care. This will help you avoid point-of-service fees.
 
Visit Emergency Care to learn more about covered emergency services, including care for psychiatric emergencies.
 
Urgent Care
Urgent care is for medical conditions that aren’t emergencies but still need professional attention within 24 hours. Examples of non-emergency conditions include sprains, sore throats, and high fevers.
 
Your rules for getting urgent care depend on your health plan and your beneficiary category. In the U.S., most types of beneficiaries can get urgent care without a referral and from any network provider or TRICARE-authorized (network or non-network) urgent care center. However, certain rules apply if you’re an active duty service member or enrolled in a TRICARE overseas plan.
 
If you aren’t sure if you need urgent care or need help finding urgent care near you, contact the Military Health System Nurse Advice Line. If you live overseas, you can also contact your TRICARE Overseas Program Regional Call Center for help.
 
To learn more about urgent care, visit Urgent Care and How To Get Urgent Care Under Your TRICARE Health Plan.
 
Routine Care
Routine care is also known as primary care. You receive routine care when you go to your primary care manager (PCM) or primary care provider (PCP) with health problems that don’t need emergency care. These providers can diagnose and treat a variety of common medical conditions and illnesses. They may also provide you with follow-up care or refer you to see a specialist for care.
 
If your plan doesn’t require you to have a PCM or PCP, you can find a doctor with the Find a Doctor tool.
 
Specialty Care
Specialty care is care from a medical professional who’s trained and licensed in a particular area of medicine. A specialist can diagnose and treat health conditions related to their field of practice. Examples of specialists include cardiologists, neurologists, and dermatologists.
 
Depending on your TRICARE plan, your beneficiary category, and the type of care you need, you may need a referral to see a specialist. If you aren’t required to have a referral, you can use the Find a Doctor tool to find a specialist.
 
Preventive Care
Preventive services diagnose health problems early or prevent problems before they start. Examples of preventive services include cancer screenings, physicals, well-child care, and immunizations (vaccines).
 
Even if you feel well, getting regular preventive care plays a key role in maintaining your long-term health. TRICARE covers many types of preventive health care exams and screenings. And as outlined in the TRICARE Costs and Fees Fact Sheet, you’ll have no out-of-pocket costs for covered preventive services received from a TRICARE network provider.
 
Being proactive on behalf of your health and your family members’ health is vital to staying healthy. Learn more about getting preventive care. And in situations when you need other types of care, know what your TRICARE plan covers.
 
Would you like the latest TRICARE news sent to you by email? Visit the TRICARE Subscriptions page today, and create your personalized profile to get benefit updates, news, and more.
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