FALLS CHURCH, Va. –
How many times will you see a medical provider this year? Will your family member need to get urgent care or see a specialist? You can’t always predict your family’s healthcare needs. But you
can know the most you could have to pay for TRICARE
covered services. TRICARE calls this your
catastrophic cap.
Your catastrophic cap limits how much you and your family will pay for TRICARE covered healthcare services each calendar year.
“When your family reaches your catastrophic cap, TRICARE pays for all remaining covered costs,” said Debra Fisher, health system specialist, Policy & Programs Branch, TRICARE Health Plan, at the Defense Health Agency. “This means you won’t be responsible for the cost of the TRICARE-allowed portion of any covered service for the rest of the year.”
Each TRICARE plan has a catastrophic cap. Knowing how your catastrophic cap works can help you make healthcare decisions for yourself and your family members.
Q: What is my TRICARE catastrophic cap amount?
A: Your catastrophic cap amount is determined by:
- Your TRICARE health plan
- Your sponsor or beneficiary type
- Your beneficiary group
- You’re in Group A if your or your sponsor’s initial enlistment or appointment began before Jan. 1, 2018.
- You’re in Group B if your or your sponsor’s initial enlistment or appointment began on or after Jan. 1, 2018.
Catastrophic cap amounts may change each year. The 2025 catastrophic cap ranges from $1,000 to $4,509, as shown in the tables below.
TRICARE Prime and TRICARE Select catastrophic caps
| Sponsor or Beneficiary Type |
Group A |
Group B |
| Active duty family members |
$1,000 per family |
$1,288 per family |
| Survivors of active duty deceased sponsor; medically retired uniformed service member and family members |
$3,000 per family |
$4,509 per family |
| Retirees, family members of retirees, and qualified unremarried former spouses |
TRICARE Prime: $3,000 per family
TRICARE Select: $4,261 per family |
$4,509 per family |
Catastrophic caps for other TRICARE plans
The catastrophic cap for
TRICARE For Life is $3,000.
Q: What costs count toward my catastrophic cap?
A:
- Copayments and cost-shares for TRICARE-covered healthcare services, inpatient and outpatient
- Enrollment fees
- Deductibles
- Pharmacy copayments and cost-shares
- Other cost-shares, based on TRICARE-allowable charges, provider type, and location
Q: What costs don’t count toward my catastrophic cap?
A: Costs that
don’t count toward your catastrophic cap include:
- Costs for services not covered by TRICARE
- Point-of-service fees
- Charges from non-participating providers. (You pay the difference between the TRICARE-allowable charge and the balance billing limit, which is up to 15% above the TRICARE-allowable charge.)
- Monthly or quarterly premiums for TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, and the Continued Health Care Benefit Program
- Extended Care Health Option sponsor and beneficiary liabilities
Q: How will I know if I’ve met my catastrophic cap?
A: Check your TRICARE
explanation of benefits. Your EOB will show how much of what you paid applied toward your family’s catastrophic cap for the claim. It’ll also show the total amount you’ve paid toward your catastrophic cap for that calendar year.
Q: What happens if I meet my catastrophic cap amount?
A: If your family reaches your catastrophic cap, TRICARE will pay your portion of the TRICARE-allowable amount for the rest of the calendar year.
Keep in mind that you’ll still have to pay fees that don’t fall under the catastrophic cap.
Your catastrophic cap will reset to $0 on Jan. 1 each year.
Q: What happens to my catastrophic cap if I change plans mid-year?
A: If you change plans during the calendar year under the same sponsor, any amount credited toward your previous catastrophic cap will be credited toward your new catastrophic cap.
Q: What other ways can I keep my out-of-pocket costs lower?
A: Because not all costs count toward your catastrophic cap, it’s important to understand
what TRICARE covers and your plan’s rules for
getting care.
Here are a few things to keep in mind before you get care.
If you have a TRICARE Prime plan (including TYA-Prime):
If you have a TRICARE Select plan or a TRICARE premium-based plan (including TYA-Select):
- You can see any TRICARE-authorized network or non-network provider. However, you’ll have lower out-of-pocket costs if you get care from a TRICARE network provider.
Looking for more information about TRICARE costs? Check out the TRICARE Costs and Fees Sheet to learn more about different types of costs associated with your TRICARE plan. Or go to Copayments & Cost-Shares to find 2025 TRICARE health plan costs.