What is the Catastrophic Cap for Tricare?

What is the Catastrophic Cap for Tricare – Overview

Every person requires extensive medical checkups, weekly doctor visits, different diagnostic tests, and long hospital tests at some point in their life.

Eventually, you may reach your catastrophic cap to maintain your health. In this article, we will talk about the catastrophic cap for Tricare.

Catastrophic Cap and Tricare

A catastrophic cap is when you need to pay the maximum part of your bill from your pocket for a covered service in a calendar year.

When a Tricare user reaches their catastrophic cap, Tricare often pays a part of that expense; the Tricare allowed amount for the rest of the calendar year.

Tricare offers different amounts for different people depending on who they are. People who use Tricare Reserve Select or TRS receive $1,000 per family yearly from Tricare. Tricare pays the same amount for all active-duty family members.

Depending on their beneficiary group, people from the retiree category receive the catastrophic cap of $3,000 or $3,500.

The catastrophic cap applies to different covered services, including pharmacy copayments, annual deductibles, and other cost shares.

What Costs Do Count Towards Your Catastrophic Cap?

What is the Catastrophic Cap for Tricare

What is the Catastrophic Cap for Tricare – Pharmacy copayments

  • The cost of healthcare services that are covered by Tricare
  • Costs for outpatient and inpatient
  • All pharmacy copayments
  • All the deductibles
  • Any other cost-shared charges depending on Tricare allowable charges, provider type, and locations

Where is the Catastrophic Cap Inapplicable?

Here are some situations where you can not apply the Catastrophic Cap.

  • Services that Tricare does not cover
  • Extended Care Health Option sponsor
  • Beneficiary liabilities
  • The Tricare prime point of service charges
  • Any charges from the nonparticipating providers
  • Enrolment fees for Tricare Select and Tricare Prime
  • Monthly premiums for Tricare Retired Reserve (TRR), Tricare Reserve Select (TRS), Tricare Young Adult (TYA), and Continued Health Care Benefits Program (CHCBP)

What Are the two Beneficiary Groups?

There are two beneficiary groups: Group A and Group B. If you or your sponsor started the initial appointment or enlistment before January 1, 2018, you belong to Group A.

However, if you or your sponsor started the initial appointment or enlistment on or after January 1, 2018, you belong to Group B.

What Happens After You Reach Your Catastrophic Cap?

When you reach your Catastrophic Cap of a calendar year, you do not have to pay for the Tricare allowable charges for any covered healthcare services.

However, you need to pay for things not under the Catastrophic Cap protection, including point of service charges, amounts billed by nonparticipating providers, and payments of all noncovered services.

If you belong to group B and reach your catastrophic year and enroll for TRR, TRS, TYA, or CHCBP, you do not have to pay for your covered services or supplies for the rest of the calendar year. However, you have to pay your monthly premiums.

If you have enrolled for Tricare Prime or Select benefits and reached your Catastrophic Cap, you do not have to pay your enrollment fees for the rest of the calendar year.

Catastrophic Cap for Tricare Prime in 2024

StatusFor Group AFor Group B
Anyone other than the active-duty family members$3,000$4,399
Medically retired service members and their families. Survivors of active duty deceased sponsor$3,000$4,399

Catastrophic Cap for Tricare Select in 2024

StatusGroup AGroup B
Anyone other than the active-duty family members$4,157$4,399
Medically retired service members and their families, Survivors of active duty, deceased sponsor$3,000$4,399

Catastrophic Cap for Tricare Prime and Tricare Select in 2024

StatusGroup AGroup B
Active duty family member$1,000$1,256

Catastrophic Cap for Active Duty Members in 2024

StatusCatastrophic Cap
Family members who are enrolled in:

Tricare Select

Tricare Prime

A combination of both Tricare Select and Tricare Prime
$1,000 per family
Spouse who are enrolled in Tricare Prime

Family members who are enrolled in Tricare Young Adult (TYA)
$1,000 for Prime enrollees

$1,256 for Tricare Young Adult (TYA) enrollees

The total family Catastrophic Cap is $1,256

Catastrophic Cap for Retirees in 2024

StatusCatastrophic Cap
Group A family members who are enrolled in Tricare Prime, Tricare Select, and a combination of both Tricare Select and Tricare Prime$3,000 per family for Prime enrollees

$4,157 per family for Select enrollees
Group A spouse and one child is enrolled in Tricare Select and another child is enrolled in Tricare Young Adult (TYA)$4,157 for Tricare Select enrollees

$4,399 for Tricare Young Adult (TYA) enrollees
Group B spouse and one child is enrolled in Tricare Select, and another child is enrolled in Tricare Young Adult (TYA)$4,399 per family

Conclusion

Tricare Catastrophic Cap offers several benefits for military people and helps them receive the required healthcare services. Tricare offers a specific amount when you reach your Catastrophic Cap, depending on certain things.

See Also

Does CVS Take Tricare?

Does Tricare Cover Chiropractic?

How Much Are Antibiotics Without Insurance?

Current Version
January 8, 2024
Updated By
Andrea Morales G.
March 1, 2023
Written By
Shubham Grover

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