MOAA’s TRICARE Toolkit provides insight and tips for navigating your TRICARE benefits. Have a question or suggestion for an upcoming column? Email beninfo@moaa.org. Read other TRICARE Toolkit columns at MOAA.org/tricaretoolkit.

One of the major benefits of TRICARE health coverage is the low annual catastrophic cap. If your family meets your catastrophic cap, then all covered care for the rest of the year will be covered at 100%. This might create planning opportunities that could save you money.

What Is a Catastrophic Cap? 

A catastrophic cap is the amount your family must pay for covered care before TRICARE starts covering that care at 100%. Catastrophic caps typically reset annually. For TRICARE, the catastrophic cap resets each year on Jan. 1.

The catastrophic cap is calculated by family expenses, though some family members might have different caps based on the TRICARE plan they use. The family nature of the catastrophic cap, with the low amounts, makes a big difference for families who receive a lot of care.

How Much Is the Cap?

Your catastrophic cap under TRICARE will vary based on the sponsor’s military status, your TRICARE group, and for some retirees, your TRICARE plan.

Group A includes beneficiaries whose sponsor entered military service prior to Jan. 1, 2018 — except for those using TRICARE Young Adult. Group B includes beneficiaries whose sponsor entered military service on or after Jan. 1, 2018, plus all TRICARE Young Adult members.

Your sponsor status may be active duty family member, TRICARE Reserve Select, TRICARE Retired Reserve, or “retirees, their families, and others.” Others would include former spouses receiving benefits under the 20-20-20 rule.

[RELATED: MOAA's TRICARE Guide]

For 2024, Group A active duty family members have a $1,000 catastrophic cap. Group B active duty family members and TRICARE Reserve Select members have a $1,256 catastrophic cap.

Retirees and associated beneficiaries have three possible catastrophic caps. For 2024, Group A members on TRICARE Prime have a $3,000 catastrophic cap, while Group A members using TRICARE Select have a $4,157 cap. Retiree status beneficiaries in Group B and TRICARE Retired Reserve members have a $4,399 cap.

TRICARE Young Adult members are different: They retain the status of their sponsor, but they pay at Group B rates even if their sponsor is in Group A.

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What Counts Toward Your Catastrophic Cap? 

Your regular deductible, copayments, and cost shares all apply toward your catastrophic cap. If you are retired, your enrollment fees also apply toward your catastrophic cap.

Premiums for TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult members do not count toward your catastrophic cap. If you are on TRICARE Prime and receive nonemergency care from anyone other than your primary care manager without a referral, your costs for this care do not apply to your catastrophic cap. This includes the TRICARE Prime point-of-service deductible and the TRICARE Prime point-of-service 50% cost-share.

Family members in different statuses might have different catastrophic caps. For example, some retiree families have some members using Prime and some using Select. Other families have children using TRICARE Young Adult. In these cases, most care contributes to everyone’s catastrophic cap, but the members with higher caps won’t hit their cap until later. This requires extra reading of your explanation of benefits to understand how things are being applied.

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How Can This Save Me Money? 

Most of us have some sort of necessary medical care that we’ve been putting off. Maybe your doctor has suggested an elective surgery. Or you’ve been
putting off trying that new medication. Or you’ve only been going to physical therapy once a week instead of twice a week.

Once you’ve met your catastrophic cap, you might want to squeeze those things in before the end of the calendar year. Doing so will be at no cost to you, assuming the care is a covered TRICARE benefit.

TRICARE’s low catastrophic caps protect you from financial hardship even if your family requires a lot of care in any given year. Understanding how it works can help you plan and even save you some money.