Beneficiary Online Handbook

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What TRICARE Covers
Urgent Care
Emergency Services 
Medical and Surgical Covered Services

WHAT TRICARE COVERS

TRICARE covers most inpatient and outpatient care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. Some military treatment facilities (MTFs) may offer services, procedures, or benefits that are not necessarily covered under TRICARE. Contact your local MTF  for more information.

A prior authorization is a process of reviewing medical, surgical, and behavioral health services to ensure medical or psychological necessity and appropriateness of care prior to services being rendered. You or your provider must contact Humana Military to obtain a prior authorization. For a list of services and/or procedures requiring prior authorization, see the section entitled "Limitations, Exculsions and Prior Authorization."

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Emergency and Urgent Care

Urgent Care
Urgent care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have 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.

Urgent care services are medically necessary services which are required for an illness or injury that would not result in further disability or death if not treated immediately, but require professional attention and have 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.


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Emergency Services
TRICARE defines an emergency as medical, maternity, or psychiatric emergencies that would lead a “prudent layperson,” (someone with average knowledge of health and medicine), 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 sight and requires immediate medical treatment or which has painful symptoms requiring immediate attention to relieve suffering.

In the event of a life-, limb-, or eyesightthreatening emergency, you should go, or be taken to, the nearest emergency department for care. In all emergency situations, you must notify your PCM or regional contractor within 24 hours of any emergency admission so that ongoing care can be coordinated (if enrolled in TRICARE Prime).


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 Medical and Surgical Covered Services
The following charts summarize TRICARE covered services. Any covered services obtained at an MTF are at no cost to you. Please note that TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) offer coverage similar to TRICARE Prime, and if enrolled, you are not responsible for deductibles, cost-shares, or copayments. However, for active duty family members (ADFMs), the waiver of copayments, cost-shares, and deductibles does not apply to pharmacy copayments, Program for Persons with Disabilities (PFPWD) cost-shares, or TRICARE Prime point-of-service (POS) cost-shares and deductibles. See the section titled “Costs and Fees”  for information about the TRICARE Prime POS option. For more information about pharmacy copayments, visit "Express Scripts."

For the services listed in these charts, TRICARE has established catastrophic caps (cat caps). Cat caps act as built-in safety nets to limit beneficiaries’ out-of-pocket expenses on TRICARE-covered medical bills. In order to get medical costs credited toward cat caps, the beneficiary may be required to provide proof of medical care, such as an explanation of benefits (EOB). Please see the section titled “Costs and Fees” for information about catastrophic caps.


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Last Reviewed: September 4, 2007