Tricare Catastrophic Cap

Tricare protects families from excessive health care expenses through the catastrophic cap, an annual out-of-pocket limit. This cap sets the maximum amount a beneficiary or family will pay in a calendar year for covered medical care. Once the cap is reached, Tricare covers 100% of all additional covered costs for the rest of the year.

The catastrophic cap is dependent on several factors, including duty station status, the Tricare plan, and the “group” – which is based on when the service member entered the military service. There are also special provisions for survivors of active-duty service members and for medically retired service members and their families.

Enrollment fees for Tricare Prime and Tricare Select are counted toward the catastrophic cap. Deductibles (which vary depending on plan type), duty status, and whether providers are in-network also apply, as well as copayments, cost-shares, and prescription costs. Premiums for special programs such as Tricare Young Adult or Tricare Reserve Select do not count toward the cap.

Understanding how the Tricare catastrophic cap works is an important financial planning tool. It can help determine how much to set aside to prepare for medical expenses. This knowledge can also help when evaluating whether to maintain additional health insurance.

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