Routine (Primary) Care
Routine (primary) care includes general office visits for the treatment of symptoms, chronic or acute illnesses and diseases, as well as follow-up care for an ongoing medical condition. Routine care also includes preventive care measures to help keep you healthy. You will receive most of your routine (primary) care from your assigned PCM or the TRICARE-authorized provider you choose as your primary care provider.
You do not need a referral or prior authorization to visit your PCM or primary care provider. If your PCM or primary care provider is unable to provide the care needed, he or she will refer you to another provider.
Services That Do Not Require Referrals
Family members may obtain some services without a PCM referral. These include clinical preventive services and the first eight outpatient behavioral health care visits per fiscal year (October 1–September 30). When seeking clinical preventive services or behavioral health care, you must use a network provider, if available. If you seek care from a non-network provider without a referral from your PCM and Humana Military, you will be utilizing the POS option, resulting in higher out-of-pocket costs. See the
TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. For more information about these services, see the
Covered Benefits, Limitations, and Exclusions section. Remember, you will not need a referral for emergency care.
Note: Active duty service members require a referral for any clinical preventive services, behavioral health care, or specialty care.
Emergency Care
TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a “prudent layperson” (someone with 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 eyesight; or a situation in which a person has painful symptoms requiring immediate attention to relieve suffering. This includes situations where a person is in severe pain or is at immediate risk to self or others.
If you need emergency care, go to the nearest emergency room or call 911. It is important that you know the local emergency telephone numbers.
| Emergency Assistance: |
| Ambulance: |
| Poison Control: 1-800-222-1222 |
You do not need to call your PCM before receiving emergency medical care. However, in all emergency situations, active duty service members must notify their PCM (if assigned) and Humana Military within 24 hours, or the next business day, so that ongoing care can be coordinated and to ensure you receive proper authorization for care. Additionally, you should contact your service point of contact (SPOC) as soon as possible.
For family members, you must notify your PCM or primary care provider within 24 hours, or the next business day, so that ongoing care can be coordinated and to ensure you receive proper authorization for care. Additional authorization for care from Humana Military may be necessary. Refer to Humana Military’s
referral and authorization list.
Urgent Care
Urgent care is 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. You would require urgent care for conditions such as a sprain, sore throat, or rising temperature that have the potential to develop into an emergency if treatment is delayed longer than 24 hours.
TPR/TPRADFM Enrollees with an Assigned PCM
If you have an assigned network PCM, you must contact them whenever you require urgent care. Your PCM will either provide the needed care or refer you to a specialist.
For active duty family members who do not coordinate urgent care with their PCM or Humana Military, the care will be covered under the point of service (POS) option, resulting in higher out-of-pocket costs. See the
TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees.
TPR/TPRADFM Enrollees Without an Assigned PCM
If you live in an area where a TRICARE provider network has not been established by Humana Military, you may seek ur.gent care from any TRICARE-authorized provider. You must have a referral from Humana Military or the care is covered under the POS option, resulting in higher out-of-pocket costs. See the
TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees.
If you are not sure if a provider is TRICARE-authorized, call Humana Military or visit our
online provider directory.
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