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Appendix G
Access Standards for TRICARE
Prime Enrollees
In the military’s purchased care system, access to substance use disorder
(SUD) care by family members and retirees1 differs somewhat by TRICARE
program. This appendix describes policies of TRICARE Prime, the largest
program used by Active and Reserve Component family members when
their military sponsor is called to active duty, as well as by retirees. Access
standards for TRICARE Prime that apply to all health care needs of ben-
eficiaries also apply to their behavioral health needs with few exceptions.
INITIAL ASSESSMENT
TRICARE Prime policy states that the initial visit to evaluate a new
or recurring behavioral health problem is considered primary care, and the
beneficiary should be evaluated by a provider who is professionally capable
or specifically privileged to perform behavioral health assessments. Family
members and retirees may choose whether to receive the initial assessment
from their primary care provider, an integrated mental health provider
within their primary care clinic, or a behavioral health care provider.
ROUTINE APPOINTMENT: NEW CONDITION
Policy states that beneficiaries requesting an appointment for a new
or recurring behavioral health condition must be seen by an appropriately
1 Ifretirees obtain Medicare Parts A and B they are no longer eligible for TRICARE Prime,
but would instead be eligible for TRICARE for Life secondary coverage to Medicare.
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370 SUBSTANCE USE DISORDERS IN THE U.S. ARMED FORCES
trained provider within 7 calendar days and within 30 minutes’ travel time
of the beneficiary’s residence. All TRICARE Prime beneficiaries have access
to a primary care provider representative by telephone around the clock.
SPECIALTY APPOINTMENTS
Following an initial behavioral health assessment, referrals for addi-
tional care are to be provided within the access standard for specialty care,
which is 4 weeks (28 days), unless the referring provider determines that
care is needed more urgently. Beneficiaries must be offered an appointment
with an appropriately trained provider within 1 hour’s travel time from
the beneficiary’s residence. Military treatment facilities have first priority
for providing referred specialty care or inpatient care for behavioral health
conditions for all TRICARE Prime beneficiaries.
PRIOR APPROVAL
Referral by a primary care provider is not required for family members
and retirees for the first eight outpatient behavioral health visits.
