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

TRICARE Plan	Group A	Group B
TRICARE Reserve Select	Follow Group B	$1,288 per family
TRICARE Retired Reserve	Follow Group B	$4,509 per family
TRICARE Young Adult	Follow Group B	Active duty family members:   $1,288  Retiree family members:   $4,509
Continued Health Care Benefit   Program	Follow Group B	$4,509 per family

 
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):

• Active duty service members: You need a referral for any care your PCM doesn’t provide. You can’t use the point-of-service option.

• All others: You need a referral for most care your PCM doesn’t provide. If you see a specialist without a referral, you’re using the point-of-service option.

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.