Catastrophic Cap

What is a Catastrophic Cap?

A catastrophic cap is the most you or your family pay for covered health care services each calendar year, starting January 1.

Once you reach your catastrophic cap, TRICARE pays your portion of the TRICARE-allowable amount for the remaining calendar year.

What Costs Count Toward my Catastrophic Cap?

Costs that DO count towards your catastrophic cap Costs that DON'T count towards your catastrophic cap
  • Costs for TRICARE-covered health care services, inpatient and outpatient
  • Enrollment fees
  • Deductibles
  • Pharmacy copayments
  • Other cost-shares, based on TRICARE-allowable amount charges, provider type, and location
  • Costs for non-covered services
  • Extended Care Health Option sponsor/beneficiary liabilities
  • Point-of-service charges
  • Charges from non-participating providers. (You pay the difference between the TRICARE allowable and the balance billing limit, i.e., up to 15% above the TRICARE allowable amount)
  • Monthly or quarterly premiums for TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), Continued Health Care Benefits Program (CHCBP)

Catastrophic Caps May Change Every Year.

  • For TYA, TRR, TRS, and CHCBP enrollees, after you meet the Group BIf you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B. DS calendar year catastrophic cap you no longer pay for covered services and supplies for the remainder of the calendar year. (You have to continue to pay your monthly premium.)
  • For TRICARE Prime and TRICARE Select enrollees, you no longer pay enrollment fees once you meet your catastrophic cap for the calendar year.

What is My Catastrophic Cap?

My Health Plan My Status Group AIf you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A. or B? Your Catastrophic Cap for 2024

TRICARE Prime

TRICARE Select

 Active duty family member A $1,000

TRICARE Prime

TRICARE Select

 Active duty family member

B

 $1,256

TRICARE Prime 

 Other than active duty family member A

$3,000

TRICARE Prime 

 Other than active duty family member

B

 $4,399

TRICARE Prime

 Survivors of active duty deceased sponsor or medically retired uniformed service member and family members

A

 $3,000

TRICARE Prime

 Survivors of active duty deceased sponsor or medically retired uniformed service member and family members

B

 $4,399

TRICARE Select

Other than active duty family member

A

 $4,157

TRICARE Select

 Other than active duty family member

B

 $4,399

TRICARE Select

 Survivors of active duty deceased sponsor or medically retired uniformed service member and family members A $3,000

TRICARE Select

 Survivors of active duty deceased sponsor or medically retired uniformed service member and family members
 B $4,399
TRICARE For Life Other than active duty family member
 A $3,000
TRICARE Reserve Select Member of the Select Reserve Group B cat cap applies $1,256
TRICARE Retired Reserve Retired member of the Select Reserve Group B cat cap applies $4,399
TRICARE Young Adult – Prime or Select Active duty family member, age 21-26 A or B: active duty family member Group B cat cap applies to both  $1,256
TRICARE Young Adult – Prime or Select
 Non-active duty family member or family member of deceased active duty sponsor or medically retired sponsor, age 21-26
A or B: other than active duty family member Group B cat cap applies to both $4,399
Continued Health Care Benefit Program (CHCBP)
 Former active duty sponsor; no longer eligible for military health care benefits
 A Group B cat cap applies $1,256
Continued Health Care Benefit Program (CHCBP)
 Retired sponsor; no longer eligible for military health care benefits
 B Group B cat cap applies $4,399

Definitions

  • Group A: Sponsor enlisted or was appointed to the uniformed services before Jan. 1, 2018.
  • Group B: Sponsor enlisted or was appointed to the uniformed services on or after Jan. 1, 2018.
  • Other than active duty family member: Retirees and their eligible family members or qualified unremarried former spouses.

Catastrophic Cap Scenarios

There may be times when certain situations affect your family’s catastrophic cap. For example, a family may have some family member enrolled in TRICARE Prime and have a family member enrolled in TRICARE Young Adult, a premium-based program.

Below are some scenarios that show what may happen to your catastrophic cap.

My Health Plan My Status Group A or B? Your Catastrophic Cap for 2024

Active duty

 Family members enrolled in TRICARE Prime, TRICARE Select, or a combination of the two (some Prime and some Select) $1000/family TRICARE Prime and TRICARE Select have the same catastrophic cap in this scenario.

Active duty

 Spouse enrolled in TRICARE Prime; family member enrolled in TRICARE Young Adult

Prime enrollees: $1000
TYA enrollee: $1,256

Total family catastrophic cap:
$1,256

 Once the family catastrophic cap is $1000, the young adult only continues to pay for health care services until the total catastrophic cap reaches $1,256

Retiree –Group A

 Family members enrolled in TRICARE Prime, TRICARE Select or a combination of the two

Prime enrollees: $3000/family

Select enrollees: $4,157/family

Once the TRICARE Prime family catastrophic cap is $3000, the TRICARE Select enrollee only continues to pay for health care services until the total catastrophic cap reaches $4,157 TRICARE

Retiree – Group A

 Spouse and one child enrolled in TRICARE Select, another child enrolled in TRICARE Young Adult

TRICARE Select enrollees: $4,157

TYA enrollee: $4,399

 Once the family catastrophic cap is $4,157, the young adult only continues to pay for health care services until the total catastrophic cap reaches $4,399

Retiree – Group B

 Spouse and one child in TRICARE Prime; another child enrolled in TRICARE Young Adult

$4,399/family

 The cat cap is the same for TRICARE Prime and TRICARE Young Adult since the sponsor is in Group B

If you have additional questions about your catastrophic cap, you can contact the appropriate servicing TRICARE contractor.


Last Updated 1/2/2024