What is the Catastrophic Cap for Tricare ā Overview
At some point in their lives, everyone requires extensive medical checkups, weekly doctor visits, different diagnostic tests, and long hospital stays.
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 the maximum out-of-pocket amount you must pay for covered services in a calendar year.
Once a Tricare beneficiary reaches their catastrophic cap, Tricare covers 100% of the Tricare-allowed amount for covered services for the remainder of the calendar year.
Tricare offers different amounts for different people depending on who they are. The catastrophic cap is $1,288 per family annually for Tricare Reserve Select beneficiaries. This cap also applies to all active-duty family members in Group B; Group A remains at $1,000.
For retirees, the catastrophic cap is set at $3,000 for Group A (Prime), $4,261 for Group A (Select), and $4,509 for Group B.
The catastrophic cap applies to covered services, including pharmacy copayments, annual deductibles, and other cost shares, but excludes premiums, point-of-service fees, and charges from non-network providers beyond allowed amounts.
What Costs Do Count Towards Your Catastrophic Cap?
- The cost of healthcare services that Tricare covers
- 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 the Catastrophic Cap does not apply.
- Services that Tricare does not cover
- Extended Care Health Option sponsor
- Beneficiary liabilities
- The Tricare prime point of service charges
- Charges from nonparticipating providers
- Enrollment fees for Tricare Select and Tricare Prime
- Monthly premiums for Tricare Retired Reserve, Tricare Reserve Select, Tricare Young Adult, and the Continued Health Care Benefit Program
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 for a calendar year, you do not have to pay the Tricare allowable charges for any covered healthcare services.
However, you need to pay for things not covered by the Catastrophic Cap protection, including point-of-service charges, amounts billed by nonparticipating providers, and payments for all non-covered services.
If you are in Group B and reach your catastrophic cap, you are not required to pay for covered services or supplies for the remainder of the calendar year. The 2025 cap is $1,288 for active duty families and $4,509 for retirees. Monthly premiums still apply.
Upon reaching the Catastrophic Cap, Tricare Prime or Select beneficiaries are not required to pay additional enrollment fees for the remainder of the calendar year.
Catastrophic Cap for Tricare Prime in 2025
| Status | For Group A | For Group B |
|---|---|---|
| Anyone other than the active-duty family members | $3,000 (Specific to TRICARE Prime) | $4,509 (For both TRICARE Prime and Select) |
| Medically retired service members and their families. Survivors of active duty deceased sponsor | $3,000 (specific to TRICARE Prime) | $4,509 (applies to both Prime and Select) |
Catastrophic Cap for Tricare Select in 2025
| Status | Group A | Group B |
|---|---|---|
| Anyone other than the active-duty family members | $4,261 (specific to TRICARE Select) | $4,509 (applies to both TRICARE Prime and Select) |
| Medically retired service members and their families, Survivors of active duty, deceased sponsor | $3,000 (specific to TRICARE Select for Group A) | $4,509 (applicable to both Prime and Select) |
Catastrophic Cap for Tricare Prime and Tricare Select in 2025
| Status | Group A | Group B |
|---|---|---|
| Active duty family member | $1,000 | $1,288 |
Catastrophic Cap for Active Duty Members in 2025
| Status | Catastrophic Cap |
|---|---|
| Family members who are enrolled in | $1,000 per family (Group A), $1,288 per family (Group B) |
| Spouse who are enrolled in Tricare Prime | $1,000 for Prime enrollees (Group A), $1,288 for Group B |
| Family members who are enrolled in Tricare Young Adult (TYA) | $1,288 for Tricare Young Adult (TYA) enrollees |
| The total family Catastrophic Cap | $1,288 |
Catastrophic Cap for Retirees in 2025
| Status | Catastrophic Cap |
|---|---|
| Group A family members who are enrolled in Tricare Prime | $3,000 per family |
| Group A family members who are enrolled in Tricare Select | $4,261 per family |
| Group B family members (Prime or Select) | $4,509 per family |
| Tricare Young Adult (TYA) with retiree sponsor | $4,509 per enrollee |
| Mixed Group A (Select + TYA) | $4,399 per family (Select cap + TYA cap applies) |
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
