The TRICARE catastrophic cap limits the amount of out-of-pocket expenses a family will have to pay for TRICARE-covered medical services. The cap applies to the allowable charges for covered services-annual deductibles, Prime enrollment fees, pharmacy co-pays, and other cost shares based on TRICARE-allowable charges. Out-of-pocket expenses paid under the TRICARE Prime point-of-service (POS) option (deductibles and cost-shares) are not applied to the annual enrollment year catastrophic cap. Additionally, any POS charges incurred after the catastrophic cap has been met are the beneficiary's financial responsibility.
What is a catastrophic cap? As a TRICARE beneficiary, you have a catastrophic cap loss protection limit (or catastrophic cap) for your health care costs. This means there is a limit to your out-of-pocket expenses.
TRICARE Prime retirees, retiree family members and survivors will have a catastrophic cap of $3,000 per enrollment year, as well as a $3,000 catastrophic cap per fiscal year. The enrollment year catastrophic cap is based on your 12-month Prime enrollment period. The fiscal year catastrophic cap runs from October 1 through September 30 each year.
Out-of-pocket expenses go in both the fiscal year and enrollment year "buckets." TRICARE enrollees will pay no more applicable out-of-pocket expenses for the rest of the enrollment year once the enrollment year catastrophic cap is met, or for the rest of the fiscal year once the fiscal year is met.
Deductibles and cost shares imposed on services provided under Point-of-Service (POS) may not be credited to the enrollment year catastrophic cap. However, enrollment fees, deductibles, copayments and cost-shares, including those assessed to POS may be credited to the fiscal year catastrophic cap.
For example, if you pay $250 out-of pocket, that $250 is credited once towards your enrollment year and again towards your fiscal year catastrophic cap.
For more information regarding this new benefit, or for information on how you may receive a reimbursement due to the catastrophic cap reduction, call your TRICARE Service Center or Beneficiary Service Representative at (800) 444-5445.
page last modified on: 5/7/2013