Emergency & Urgent Care Are Not the Same

Is it a sprain or a break? Is your child’s fever holding steady, or has it gone up since you last checked? The first priority when you or a loved one is sick or hurting is to get help, but you should be aware of the differences between emergency and urgent care, to avoid high out-of-pocket costs.

What is an Emergency?

TRICARE defines an emergency as a medical condition that a "prudent layperson" – someone with an average knowledge of health and medicine – believes could threaten life, limb or eyesight without immediate treatment. If you feel the situation requires immediate medical treatment, or there are painful symptoms requiring immediate attention to relieve suffering, the situation is an emergency. Examples of emergency situations include but are not limited to the following:

In an emergency, you should go to or be taken to the nearest emergency room for treatment. You or someone on your behalf should then contact your primary care manager (PCM) or TriWest within 24 hours if the emergency room visit results in an inpatient admission, so ongoing care can be coordinated.

How is Urgent Care Different?

An urgent condition is an illness or injury that won’t cause further disability or death if you’re not treated immediately, but requires professional attention to prevent it from developing into a greater threat.

Urgent care is typically provided by your PCM. Urgent care centers should be used only if your PCM is not available. If you are traveling, you must coordinate with your PCM or TriWest before receiving urgent care. If not, you will be covered under TRICARE Prime’s point-of-service option, which includes additional cost-shares and a deductible. Examples of urgent care situations include but are not limited to the following:

It’s important for you to receive the proper referrals and/or print authorization from your PCM or TriWest before receiving care, or you may have to pay higher POS fees.