How Does the TRICARE Catastrophic Cap Work?
When it comes to staying healthy, some years are better than others. Perhaps you or your family faced a bumpy road this year. There may have been extensive medical tests or procedures, lengthy hospital stays, or weekly doctor visits. You may have reached — or are close to reaching — your catastrophic cap. A catastrophic cap is the most you pay out of pocket for covered services each year. This protects you because it limits the amount of out-of-pocket expenses a family pays for TRICARE covered medical services.
Your catastrophic cap amount depends on who you are. For active duty family members or families using TRICARE Reserve Select (TRS), the cap is $1,000 per family, per year. Those in a retiree category have a catastrophic cap of either $3,000 or $3,500, depending on your beneficiary group: Group AClick to closeIf you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A. or Group BClick to closeIf you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B..
The catastrophic cap applies to all covered services. This includes annual deductibles, pharmacy copayments, and other cost-shares based on TRICARE-allowable charges. The catastrophic cap doesn’t apply to:
- Services not covered by TRICARE
- Any amount that non-participating providers may charge above the TRICARE-allowable chargeClick to closeThe maximum amount TRICARE pays for each procedure or service. This is tied by law to Medicare's allowable charges. for services
- TRICARE Prime point-of-service charges
- Enrollment fees for TRICARE Prime and TRICARE Select
- Monthly premiums for TRS, TRICARE Retired Reserve or TRICARE Young Adult
What happens when you reach your catastrophic cap in a calendar year? You don’t pay any more of the TRICARE-allowable charge for covered services. But you’ll have to pay for services that don’t fall under the catastrophic cap protection. These include amounts billed by non-participating providers (up to 15 percent above the allowable charge), point-of-service charges, and all costs for non-covered services.
If you’re an active duty member who retires mid-year, don’t worry. The full deductible and cost-shares credited towards the previous family cap will be credited to the new cap.
Learn more about TRICARE costs or download the Costs and Fees Sheet on the TRICARE Publications page. You can also view and compare health plan costs using the new TRICARE Plan Comparison Tool. Take command of your health and understand your TRICARE benefit in 2018.
Last Updated 4/26/2019