1.1 TRICARE
Prime enrollees shall select or have assigned to them PCMs according
to guidelines established by the Military Treatment Facility (MTF)
Commander/Enhanced Multi-Service Market (eMSM) Manager and Director,
TRICARE Regional Offices (TROs).
1.1.1 A PCM
may be a network provider, or an MTF/eMSM PCM by name/supported
by a team. If a group practice is listed as a network provider,
all members of the group practice must be TRICARE-authorized providers.
1.1.2 The following types of individual
professional providers are considered primary care providers and
may be designated PCMs, consistent with governing State rules and
regulations: internists, family practitioners, pediatricians, General
Practitioners (GPs), obstetricians/gynecologists (OB/GYNs), Physician
Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse
Midwives (CNMs).
1.2 A TRICARE
Prime enrollee must seek all his or her primary health care from
the PCM with the exception of Clinical Preventive Services. If the
PCM is unable to provide a primary care service, the PCM is responsible
for referring the enrollee to another primary care provider. A TRICARE
Prime enrollee must be referred by the PCM for specialty care or
for inpatient care. For mental health and Substance Use Disorder
(SUD) care, all inpatient and outpatient services, except office-based,
outpatient treatment provided by a network provider, require a referral.
However, if the non-office based, outpatient mental health or SUD
provider is a network provider, a request for preauthorization from
the network provider to the contractor may be accepted in lieu of
PCM referral. Failure to obtain a PCM referral when one is required
will result in the service being paid under Point of Service (POS) procedures
with a deductible for outpatient services and cost-shares for in-
and outpatient services.
A temporary waiver of the
referral requirement for TRICARE Prime enrollees, not including
Active Duty Service Members (ADSMs), for the Coronavirus 2019 (COVID-19)
vaccine is authorized. The COVID-19 vaccine is a clinical preventive
service and under this waiver it may be obtained from any TRICARE
Basic (medical) program authorized non-network provider without
incurring POS charges, where applicable. See Chapter 1, Section 15.1.