How does the TRICARE catastrophic cap work?

The catastrophic cap protects you from excessive healthcare costs:

What It Is • Maximum you pay per fiscal year (Oct 1 - Sept 30) • After reaching cap, TRICARE pays 100% • Applies to covered services only

2024 Catastrophic Caps • Active Duty Family Members: $1,000 • Retirees (Group A): $3,000 • All others: $3,500

What Counts Toward Cap • Annual deductibles • Copayments • Cost-shares • Pharmacy copays (Select only)

What Doesn't Count • Enrollment fees • Premiums • Non-covered services • Balance billing amounts • Services exceeding allowable charges

How It Works

Example for ADFM • Annual cap: $1,000 • Throughout year, pay copays and cost-shares • Once total reaches $1,000 • Rest of fiscal year: $0 out-of-pocket

Tracking Your Cap • TRICARE tracks automatically • Check through online portal • Review Explanation of Benefits (EOB) • Contact contractor for current total

Important Notes • Resets October 1 each year • Separate caps for Prime and Select • Family expenses combine toward cap • Moving between plans may affect tracking

Common Questions

Q: Does my enrollment fee count? A: No, only cost-shares and deductibles

Q: Do I need to file paperwork? A: No, TRICARE tracks automatically

Q: What if I switch plans? A: Expenses may not transfer between plan years

Benefits • Financial protection • Predictable maximum costs • Peace of mind for chronic conditions • Helpful for major medical events

For Families • All family members' costs combine • Protects entire household • One cap per family

The catastrophic cap ensures healthcare costs remain manageable, especially valuable for families with significant medical needs.