Kathleen Larkin, Director, Health Plan Policy Division of Health Affairs/ TRICARE Management Activity
Two days into your summer vacation, you sprain your ankle while jet skiing. Even the best planned vacations can be disrupted with injury or sickness. While your TRICARE benefit follows you when you travel, understanding when something constitutes an emergency room or urgent care visit can help you save money and time.
TRICARE defines an emergency as a medical, maternity or psychiatric condition that would lead a “prudent layperson” (someone with an average knowledge of health and medicine) to believe that a serious medical condition exists; that the absence of immediate medical attention would result in a threat to life, limb or sight; when a person has severe, painful symptoms requiring immediate attention to relieve suffering or when a person is at immediate risk to self or others.
Some examples of emergency situations may include: head injury, broken bones, chest pains and inability to breath. If you or a family member requires emergency care while on vacation, call 911 immediately or go to the nearest ER. If you are admitted, you must notify your primary care manager (PCM) or regional health care contractor within 24 hours or on the next business day to coordinate ongoing care. Prior authorization is not required for emergency care before receiving treatment.
If you and your family are vacationing overseas, you can obtain assistance with locating an emergency facility or emergency number for the country you are visiting by calling the TRICARE Overseas Program (TOP) contractor. Go to TRICARE’s contact us web page.
When seeking care from a host nation (overseas) provider, you should be prepared to pay up front for services and then file a claim with the TOP claims processor. Active duty service members (ADSMs) and Prime enrolled active duty family members should contact the TOP regional call center in that area prior to seeking care when possible or prior to making payment.
TRICARE defines urgent care as a medical service needed within 24 hours when an illness or injury would not result in further disability or death if not treated immediately. Some examples of urgent care situations may include: earache, toothache, sprain or urinary tract infection.
If urgent care treatment cannot wait until you return home to see your PCM, you must contact your PCM for a referral or call your regional health care contractor for assistance before receiving care. Failure to obtain a referral may cause your care to be covered under the point-of-service (POS) option and you will incur higher costs. The POS option does not apply to ADSMs, newborn or adopted children in their first 60 days, emergency care or if you have other health insurance. Visit TRICARE’s website for POS details.
ADSMs should seek urgent care at a military treatment facility (MTF). If away from home, ADSMs should contact their regional health care contractor for assistance in obtaining urgent care. ADSMs located overseas who are unable to seek urgent care at an MTF should contact the TOP regional call center.
You may use any TRICARE pharmacy option when you are vacationing, but be sure your DEERS information is current. To fill a prescription, you need a valid uniformed services identification card. At overseas host nation pharmacies, you will pay up front and file for reimbursement of covered charges with the overseas claims processor. To locate a pharmacy or for additional details, visit www.tricare.mil/pharmacy.
If you require emergency dental care, contact the dental care program you are enrolled in for further assistance.
Don’t let an injury or sickness ruin your vacation. Be prepared by knowing your TRICARE benefit. Also, it’s always a good idea to pack an emergency kit.