Understanding TRICARE Costs: A Guide to Copays, Deductibles, and Catastrophic Caps

Last updated 6 months ago. Our resources are updated regularly but please keep in mind that links, programs, policies, and contact information do change.

TRICARE serves as the healthcare program for millions in the U.S. uniformed services community, including active duty personnel, retirees, National Guard and Reserve members, their families, and survivors worldwide.

This guide provides a clear explanation of the various out-of-pocket expenses associated with TRICARE. By understanding key cost terms, how costs differ across TRICARE plans and beneficiary groups, pharmacy expenses, and the protection offered by the catastrophic cap, you can better manage your healthcare spending and make informed decisions about your coverage and care.

Key TRICARE Cost Terms

Understanding TRICARE requires familiarity with specific terminology for out-of-pocket expenses. These costs vary depending on your TRICARE plan, beneficiary category, type of medical service, and chosen provider.

Copayment (Copay)

A copayment or “copay” is a fixed dollar amount you pay for a specific covered healthcare service or prescription drug. Copays are common in TRICARE Prime plans (for retirees and their families) and for services from network providers under TRICARE Select. They also apply to prescriptions filled outside military pharmacies.

Active Duty Service Members (ADSMs) typically don’t have copayments for covered services. For those in TRICARE Prime or TRICARE Prime Remote (excluding ADSMs), a single copayment for an appointment often covers associated costs for basic tests performed during that visit.

Deductible

The annual deductible is the amount you must pay out-of-pocket for covered healthcare services and prescriptions within a calendar year (January 1 to December 31) before TRICARE begins to share costs.

Annual deductibles apply to:

• TRICARE Select
• TRICARE Select Overseas
• TRICARE Reserve Select (TRS)
• TRICARE Retired Reserve (TRR)
• TRICARE Young Adult (TYA)-Select option
• TRICARE For Life (TFL) for services covered by TRICARE but not by Medicare

TRICARE Prime plans generally don’t have an annual deductible for most services, except when using the Point-of-Service (POS) option for non-referred, non-emergency care.

Deductible amounts vary based on your specific plan and beneficiary group. Find your plan’s deductible amounts at TRICARE Deductibles FAQ.

Cost-Share

A cost-share is the percentage of the TRICARE-allowable charge for a covered healthcare service that you pay. This applies across all TRICARE plans, although ADSMs are exempt.

Cost-shares typically apply after meeting the annual deductible in plans like TRICARE Select, particularly when using non-network providers, though they can apply to certain services even with network providers.

Since cost-shares are percentage-based, the amount paid scales with the service cost. For complex medical situations involving multiple providers, these percentage-based cost-shares can accumulate, potentially leading to significant out-of-pocket expenses compared to fixed copayments.

Enrollment Fee / Premium

These are recurring payments required to establish or maintain coverage under specific TRICARE plans:

• Annual enrollment fees apply to TRICARE Prime and TRICARE Select plans for retirees, their eligible family members, and certain other beneficiary categories.
• Active Duty Family Members (ADFMs) and transitional survivors generally don’t pay enrollment fees for Prime or Select.
• Monthly premiums are required for enrollment in TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), and the Continued Health Care Benefit Program (CHCBP).

Annual enrollment fees for Prime and Select count toward reaching the catastrophic cap, whereas monthly premiums for TRS, TRR, TYA, and CHCBP do not.

Catastrophic Cap

The Catastrophic Cap is an annual financial safety net representing the maximum amount a beneficiary or family must pay out-of-pocket for TRICARE-covered services during a calendar year (January 1 – December 31).

Once this limit is reached, TRICARE generally pays 100% of the TRICARE-allowable charges for most covered services for the remainder of that calendar year. This cap applies to all TRICARE plans, but the specific dollar amount varies considerably based on the plan and beneficiary status.

Allowable Charge

This is the maximum payment amount that TRICARE will reimburse a healthcare provider for a specific procedure, service, or equipment. This amount is often linked by law to Medicare’s established rates and can vary based on geographic location due to differing healthcare costs.

The allowable charge forms the basis for calculating cost-shares and represents the payment ceiling that network and participating providers agree to accept.

Balance Billing

Balance billing occurs when a non-participating, TRICARE-authorized provider bills you for the difference between their full billed charge and the TRICARE allowable charge.

TRICARE network providers and participating non-network providers are contractually forbidden from balance billing. Non-participating providers, however, can bill beneficiaries for amounts up to 15% above the TRICARE allowable charge.

You are personally responsible for paying this additional 15% charge, on top of any applicable deductible and regular cost-share. Amounts paid due to balance billing do not count toward the annual Catastrophic Cap.

For official definitions and further details on these terms, visit the TRICARE Cost Terms page.

Beneficiary Categories and Groups

TRICARE eligibility is determined by the sponsor’s branch of the uniformed service, with eligibility status recorded in the Defense Enrollment Eligibility Reporting System (DEERS). Maintaining accurate information in DEERS is essential for accessing TRICARE benefits. You can verify eligibility through the milConnect portal.

TRICARE benefits, plan options, and costs vary significantly depending on your specific category:

• Active Duty Service Members (ADSMs): Generally enrolled in TRICARE Prime or Prime Remote with no out-of-pocket costs for covered services.
• Active Duty Family Members (ADFMs): Spouses and eligible children of ADSMs. Have options like Prime, Select, or USFHP, often with minimal or no costs under Prime.
• National Guard/Reserve Members and Families: Eligibility and plan options depend on the sponsor’s duty status.
• Retired Service Members and Families: Includes those who completed a qualifying period of service and those medically retired. Options typically include Prime (if available), Select, USFHP (if available), and TRICARE For Life if Medicare-eligible. Costs are generally higher than for ADFMs.
• Retired Reserve Members and Families: Members under age 60 may qualify to purchase TRICARE Retired Reserve (TRR). At age 60, they gain eligibility similar to other retired service members.
• Survivors: Eligible family members of deceased sponsors. Benefits depend on the sponsor’s status at time of death; transitional survivors of ADSMs often retain ADFM cost structures for a period.
• Former Spouses: May be eligible under specific conditions related to length of marriage and service.
• Medal of Honor Recipients and Families: Specific eligibility category.
• Children: Generally eligible until age 21, or 23 if enrolled full-time in college and financially dependent on the sponsor. Eligibility may extend further for children with severe disabilities. The TRICARE Young Adult plan offers purchased coverage up to age 26.
• Medicare-Eligible Beneficiaries: Those entitled to Medicare Part A and enrolled in Part B are typically covered by TRICARE For Life.

Group A vs. Group B

An additional factor in cost determination is the division of beneficiaries into Group A or Group B, based on the sponsor’s initial date of enlistment or appointment into the uniformed services:

• Group A: Applies if the sponsor’s initial enlistment or appointment occurred before January 1, 2018.
• Group B: Applies if the sponsor’s initial enlistment or appointment occurred on or after January 1, 2018.

This distinction is crucial because Group A and Group B beneficiaries often face different enrollment fees, annual deductibles, and catastrophic caps, particularly under TRICARE Select and for retirees enrolled in TRICARE Prime. Generally, Group B cost thresholds and enrollment fees are higher than those for Group A.

Beneficiaries enrolled in premium-based plans—TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), and the Continued Health Care Benefit Program (CHCBP)—follow the Group B cost structures regardless of their sponsor’s original entry date.

You can verify your group designation using the guidance at TRICARE Group Designation FAQ.

Major TRICARE Health Plans

TRICARE offers various health plan options, with eligibility determined by factors like the sponsor’s military status, the beneficiary’s relationship to the sponsor, geographic location, and Medicare eligibility. To navigate these options, TRICARE provides online tools: the TRICARE Plan Finder helps identify potentially eligible plans, while the Compare Plans tool allows side-by-side feature comparison.

Managed Care Plans

These plans generally have lower out-of-pocket costs and are network/referral-based:

• TRICARE Prime / TRICARE Prime Overseas: These plans function like Health Maintenance Organizations (HMOs) and are available in designated Prime Service Areas (PSAs) in the U.S. and overseas. Enrollment is required. Beneficiaries are assigned a Primary Care Manager (PCM) who manages their care and provides referrals for most specialty services. These plans typically feature the lowest out-of-pocket costs, especially for ADFMs who generally pay $0 for covered services. ADSMs are required to enroll in a Prime plan. Learn more at TRICARE Prime.
• TRICARE Prime Remote (TPR) / TRICARE Prime Remote Overseas: These options extend the Prime model to ADSMs and their eligible families who live and work in designated remote locations, typically defined as being more than 50 miles or one hour’s drive time from a Military Treatment Facility (MTF).
• US Family Health Plan (USFHP): An additional TRICARE Prime option available only in six specific geographic areas across the U.S., delivered through established networks of community-based, not-for-profit healthcare systems. Enrollees receive all their care, including pharmacy services, exclusively through the designated USFHP provider network and cannot use MTFs or other TRICARE network providers or pharmacies. ADFMs enrolled pay no fees or out-of-pocket costs, while retirees pay annual enrollment fees and network copayments. More information at TRICARE USFHP.

PPO-Style Plans

These plans generally have higher out-of-pocket costs but offer more provider choice:

• TRICARE Select / TRICARE Select Overseas: These plans function like Preferred Provider Organizations (PPOs) and are available stateside and overseas. Enrollment is required for most eligible beneficiaries. The main feature is flexibility: beneficiaries can see any TRICARE-authorized provider, whether in the TRICARE network or not, without needing a referral for most primary and specialty care visits. However, some services may still require pre-authorization from the regional contractor. While offering choice, these plans come with annual deductibles and cost-shares or copayments for services. Out-of-pocket costs are generally lower when using providers within the TRICARE network compared to non-network providers. Details at TRICARE Select.

Medicare-Related Plan

• TRICARE For Life (TFL): This is not a plan you enroll in, but rather automatic coverage for TRICARE beneficiaries who are entitled to Medicare Part A and enrolled in Medicare Part B. TFL acts as “wraparound” coverage, meaning it pays after Medicare pays its share for services covered by both programs, significantly reducing out-of-pocket costs for beneficiaries in the U.S. Overseas, where Medicare generally doesn’t provide coverage, TFL becomes the primary payer. TFL beneficiaries generally only incur TRICARE deductibles or cost-shares for services covered by TRICARE but not by Medicare. Further details at TRICARE For Life.

Premium-Based Plans

These plans offer coverage options for specific populations who might not otherwise be eligible for regular TRICARE plans, but they require monthly premiums:

• TRICARE Reserve Select (TRS): A PPO-style plan available for purchase by qualified members of the Selected Reserve and their eligible families. It provides coverage similar to TRICARE Select, using the same network/non-network cost structure and adhering to Group B cost levels. Monthly premiums are required. Eligibility requires that the member is not eligible for or enrolled in the Federal Employees Health Benefits (FEHB) program. Information at TRICARE Reserve Select.
• TRICARE Retired Reserve (TRR): This premium-based, PPO-style plan is available for purchase by qualified members of the Retired Reserve who are under age 60, and their eligible families. Like TRS, it mirrors TRICARE Select coverage and uses Group B cost structures. TRR requires significantly higher monthly premiums compared to TRS. Details at TRICARE Retired Reserve.
• TRICARE Young Adult (TYA): An option that qualified dependent children can purchase when they age out of regular TRICARE coverage (typically at age 21, or 23 if enrolled full-time in college) but are not yet 26. TYA offers both a Prime option (TYA-Prime) and a Select option (TYA-Select), each requiring its own monthly premium. The costs associated with TYA depend on whether the Prime or Select option is chosen, but both follow the Group B cost structures. More information at TRICARE Young Adult.

Other Options

• TRICARE Plus: This is not a full health plan but a primary care enrollment program offered at some MTFs. It allows beneficiaries who are not enrolled in TRICARE Prime (like those using TRICARE Select or TFL) to enroll for primary care services specifically at that MTF where they are enrolled. It does not cover specialty care and access is limited to the enrolling MTF.

A helpful summary of these plans is available in the TRICARE Plans Overview Fact Sheet.

Comparing Costs: TRICARE Prime vs. TRICARE Select (Calendar Year 2025)

The choice between TRICARE Prime and TRICARE Select often comes down to balancing out-of-pocket costs against provider choice and flexibility. This section details the specific costs for these two primary enrollment plans effective for the 2025 calendar year (January 1 – December 31, 2025), highlighting the significant differences based on beneficiary status (ADFM vs. Retiree/Other) and the Group A/B designation. For the most personalized and current cost details, use the TRICARE Compare Costs tool.

TRICARE Prime Costs (CY 2025)

Active Duty Family Members (ADFMs) & Transitional Survivors:

• Enrollment Fee: $0
• Annual Deductible: $0
• Service Costs: $0 for all covered services when following plan rules (e.g., using PCM referrals)
• Annual Catastrophic Cap: Group A: $1,000 per family; Group B: $1,288 per family

Retirees, Their Family Members, and Others:

• Annual Enrollment Fee:
  • Group A: $372 per individual / $744 per family (Note: Fees for some Group A beneficiaries, like medically retired sponsors and survivors classified before 2020, may differ based on their classification date)
  • Group B: $450 per individual / $900.96 per family
• Annual Deductible: $0
• Annual Catastrophic Cap: Group A: $3,000 per family; Group B: $4,509 per family

Key Service Copayments (when using network providers and referrals):

• Clinical Preventive Services: $0
• Primary Care Outpatient Visit: $25
• Specialty Care Outpatient Visit: $38
• Urgent Care Visit (at TRICARE-authorized UCC): $38
• Emergency Room Visit: $77
• Inpatient Hospital Admission: $193 per admission
• Mental Health Outpatient Visit (Primary Care PCM): $25
• Mental Health Outpatient Visit (Specialty Care): $38
• Mental Health Inpatient Admission (Network): $193 per admission

TRICARE Prime Point-of-Service (POS) Option: This applies when a Prime enrollee (other than an ADSM) seeks non-emergency care from a TRICARE-authorized provider without obtaining a required referral from their PCM.

• POS Costs: Beneficiaries face a separate annual POS deductible ($300 for an individual / $600 for a family). After meeting this deductible, they must pay a 50% cost-share of the TRICARE-allowable charge for services received under the POS option.
• POS and the Catastrophic Cap: Costs incurred under the POS option—both the POS deductible and the 50% cost-share—do not count toward the regular annual Catastrophic Cap.

TRICARE Select Costs (CY 2025)

Active Duty Family Members (ADFMs) & Transitional Survivors:

• Annual Enrollment Fee: $0
• Annual Deductible: Varies by sponsor’s pay grade and beneficiary group:
  • Group A: E-4 and below: $50 Individual / $100 Family; E-5 and above: $150 Individual / $300 Family
  • Group B: E-4 and below: $64 Individual / $128 Family; E-5 and above: $193 Individual / $386 Family
• Annual Catastrophic Cap: Group A: $1,000 per family; Group B: $1,288 per family

Key Service Costs (Network Provider Copay / Non-Network Provider Cost-Share after deductible):

• Clinical Preventive Services: $0 (Network) / $0 (Non-Network)
• Primary Care Outpatient Visit: Group A: $27 / 20%; Group B: $19 / 20%
• Specialty Care Outpatient Visit: Group A: $38 / 20%; Group B: $32 / 20%
• Urgent Care Visit: Group A: $27 / 20%; Group B: $25 / 20%
• Emergency Room Visit: Group A: $105 / 20%; Group B: $51 / 20%
• Inpatient Hospital Admission: Group A: $23.45 per day (min $25/admission) / Same; Group B: $77 per admission / 20%
• Mental Health Outpatient Visits (Primary/Specialty): Costs mirror regular Primary/Specialty care visits
• Mental Health Inpatient Admission: Costs mirror regular Inpatient Hospital Admission costs

Retirees, Their Family Members, and Others:

• Annual Enrollment Fee:
  • Group A: $181.92 per individual / $364.92 per family
  • Group B: $579 per individual / $1,158.96 per family
• Annual Deductible:
  • Group A: $150 per individual / $300 per family
  • Group B: Network provider use: $193 Individual / $386 Family; Non-Network provider use: $386 Individual / $772 Family (Note: For Group B, prescription costs also apply toward meeting the deductible, and the deductible is higher if using non-network providers)
• Annual Catastrophic Cap: Group A: $4,261 per family; Group B: $4,509 per family (Note: A lower cap of $3,000 applies to Group A retirees who are survivors of ADSMs or medically retired sponsors and their dependents)

Key Service Costs (Network Provider Copay / Non-Network Provider Cost-Share after deductible):

• Clinical Preventive Services: $0 (Network) / $0 (Non-Network)
• Primary Care Outpatient Visit: Group A: $37 / 25%; Group B: $32 / 25%
• Specialty Care Outpatient Visit: Group A: $51 / 25%; Group B: $51 / 25%
• Urgent Care Visit: Group A: $37 / 25%; Group B: $51 / 25%
• Emergency Room Visit: Group A: $140 / 25%; Group B: $103 / 25%
• Inpatient Hospital Admission: Group A Network: $250/day (up to 25% of hospital charges) + 20% of separately billed services / Non-Network: Higher daily limit + 25% of separately billed services; Group B Network: $225 per admission / Non-Network: 25% cost-share
• Mental Health Outpatient Visits (Primary/Specialty): Costs mirror regular Primary/Specialty care visits
• Mental Health Inpatient Admission: Costs mirror regular Inpatient Hospital Admission costs

Table 1: TRICARE Prime vs. Select Key Cost Comparison (CY 2025, Group B Focus)

This table provides a high-level comparison to illustrate the fundamental cost differences between Prime and Select for different beneficiary types, using the Group B cost structure as a baseline relevant for new entrants and premium plans. Significant Group A differences are noted.

Notes: ¹ Group A Retiree Prime Fee: $744/family. ² Group A Retiree Select Fee: $364.92/family. ³ Group A Select ADFM Deductible: E4/below $100/family, E5/above $300/family. ⁴ Group A Select Retiree Deductible: $300/family (Network or Non-Network). ⁵ Group A ADFM Cap: $1,000/family. ⁶ Group A Retiree Cap: Prime $3,000/family, Select $4,261/family (or $3,000 for survivors/medically retired). ⁷ Group A Select ADFM Primary Care Net Copay: $27. Non-Network Cost-Share: 20% for A & B. ⁸ Group A Select Retiree Costs: Primary Net $37, Specialty Net $51, ER Net $140, Inpatient Net complex daily rate. Non-Network Cost-Share: 25% for A & B. ⁹ Group A Select ADFM Specialty Care Net Copay: $38. Non-Network Cost-Share: 20% for A & B. ¹⁰ Group A Select ADFM ER Net Copay: $105. Non-Network Cost-Share: 20% for A & B. ¹¹ Group A Select ADFM Inpatient Admission: $23.45/day (min $25/admission) for Net & Non-Net.

Costs for Other TRICARE Plans (Calendar Year 2025)

Beyond Prime and Select, other TRICARE plans have distinct cost structures.

TRICARE For Life (TFL)

TFL coverage is automatic for those with Medicare Parts A and B.

Primary Cost Driver: The main ongoing cost for TFL beneficiaries is the monthly premium for Medicare Part B, which is required to maintain TRICARE eligibility for most beneficiaries once they become Medicare-eligible. Medicare Part A is typically premium-free for those with sufficient work history. Part B premiums are set by Medicare and vary based on income.

TRICARE-Specific Costs: There is no separate enrollment fee for TFL itself. When receiving services covered by both Medicare and TRICARE in the U.S., Medicare pays first, and TFL typically covers the remaining Medicare deductible and cost-share, resulting in minimal out-of-pocket costs for the beneficiary for those services.

For services covered by TRICARE but not by Medicare, the beneficiary may be responsible for the TRICARE deductible and cost-shares. TFL has its own annual catastrophic cap of $3,000 per family for these TRICARE-specific costs.

Premium-Based Plans (TRS, TRR, TYA, CHCBP)

These plans require beneficiaries to actively enroll and pay recurring premiums for coverage.

General Cost Structure: Enrollees in TRS, TRR, and TYA-Select generally follow the TRICARE Select cost-sharing rules (annual deductibles, network copayments, non-network cost-shares) based on Group B cost levels. TYA-Prime enrollees follow TRICARE Prime cost-sharing rules (network copays, POS rules) based on Group B levels.

Primary Cost Driver: The most significant cost associated with these plans is the recurring premium (paid monthly for TRS, TRR, TYA; quarterly for CHCBP). These premiums do not count toward the beneficiary’s annual catastrophic cap. This means enrollees must budget for the full premium cost regardless of how much they spend on healthcare services during the year.

Catastrophic Caps (CY 2025):

• TRICARE Reserve Select (TRS): $1,288 per family
• TRICARE Retired Reserve (TRR): $4,509 per family
• TRICARE Young Adult (TYA) – Prime or Select: Depends on sponsor status; $1,288 if based on ADFM status, $4,509 if based on Retiree Family Member status
• Continued Health Care Benefit Program (CHCBP): $4,509 per family

Table 2: Premium-Based Plan Monthly Premiums (CY 2025)

This table highlights the premium costs associated with these purchased plans.

¹ CHCBP premiums are billed quarterly. Monthly amounts are approximate for comparison.

Understanding Your Pharmacy Costs (Effective Jan 1, 2024 – Dec 31, 2025)

TRICARE provides comprehensive prescription drug coverage through the TRICARE Pharmacy Program, administered by Express Scripts. Costs for medications vary based on the drug’s category (generic, brand-name formulary, non-formulary), where the prescription is filled, and the beneficiary’s status. The costs outlined here are effective from January 1, 2024, through December 31, 2025. Active Duty Service Members (ADSMs) pay $0 out-of-pocket for covered medications obtained through military pharmacies, TRICARE Pharmacy Home Delivery, or TRICARE retail network pharmacies.

Pharmacy Options and Cost Hierarchy

TRICARE offers several ways to fill prescriptions, structured to encourage the use of more cost-effective options:

Military Pharmacy (MTF Pharmacy): This is typically the lowest-cost option. Beneficiaries pay $0 copay for up to a 90-day supply of most covered medications. However, non-formulary drugs (medications not on TRICARE’s preferred list) are generally not available at MTF pharmacies unless deemed medically necessary by a provider. Find locations at TRICARE Military Pharmacy Locator.

TRICARE Pharmacy Home Delivery: Managed by Express Scripts, this option offers the convenience of receiving up to a 90-day supply of maintenance medications delivered directly to your home with free standard shipping. Copayments are lower than retail network pharmacies, making it a cost-effective choice for drugs taken regularly. ADSMs pay $0. More info at TRICARE Home Delivery.

TRICARE Retail Network Pharmacies: This network includes thousands of civilian pharmacies across the country. It offers convenience for filling prescriptions quickly, typically for up to a 30-day supply. Copayments are higher than home delivery.

Non-Network Pharmacies: Using a pharmacy outside the TRICARE network results in the highest costs and inconvenience. Beneficiaries must pay the full price for the medication upfront and then file a claim with TRICARE for partial reimbursement. Reimbursement is subject to deductibles, copayments, or cost-shares.

Specifically, TRICARE Prime beneficiaries using a non-network pharmacy fall under Point-of-Service rules, paying a 50% cost-share after meeting the POS deductible. Other beneficiaries (e.g., TRICARE Select) pay a higher copayment ($43 for formulary, $76 for non-formulary in 2024-2025) or 20% of the total cost (whichever is greater), after meeting their plan’s annual deductible.

Overseas Pharmacies: Procedures and costs vary overseas. Beneficiaries may need to pay upfront and file a claim for reimbursement. Costs depend on the plan and status (e.g., ADFMs on Prime Overseas pay $0 after filing, while Select Overseas retirees pay a 25% cost-share after the deductible).

Drug Categories and the Formulary

TRICARE categorizes drugs to manage costs and promote effectiveness:

Generic Formulary Drugs: These drugs are chemically equivalent to brand-name drugs and meet FDA standards. They are on TRICARE’s preferred list (formulary) and have the lowest copayments.

Brand-Name Formulary Drugs: These are patented drugs on the TRICARE formulary. They have higher copayments than generics.

Non-Formulary Drugs: These drugs are not on TRICARE’s preferred list. They have the highest copayments and may require pre-authorization or a determination of medical necessity to be covered. They are generally not available at military pharmacies.

Non-Covered Drugs: TRICARE does not cover these drugs. Beneficiaries must pay the full cost out-of-pocket.

You can check if your medication is covered and see its category using the TRICARE Formulary Search Tool, typically found via the Express Scripts website linked from tricare.mil (e.g., Express Scripts TRICARE Formulary Search Tool).

Some medications may also be subject to quantity limits or require step therapy (trying a preferred drug first).

Table 3: TRICARE Pharmacy Copayments (Per Prescription, Jan 1, 2024 – Dec 31, 2025)

This table summarizes the copayments for most beneficiaries (excluding ADSMs, whose cost is $0 at MTF/Home/Network).

¹ Non-formulary drugs generally require medical necessity justification at MTF pharmacies. ² Non-Network Costs: Beneficiary pays full price upfront and files claim. Costs shown apply after meeting applicable deductible. ³ Non-Network Costs for Prime beneficiaries: 50% cost-share after POS deductible. For all other beneficiaries: Pay the greater of the fixed copay ($43 for formulary, $76 for non-formulary) or 20% of total cost, after meeting annual plan deductible.

The Catastrophic Cap: Your Annual Out-of-Pocket Safety Net (Calendar Year 2025)

One of the most important features of TRICARE is the annual Catastrophic Cap (CC). This acts as a crucial financial protection for beneficiaries by limiting the maximum amount a family pays out-of-pocket for TRICARE-covered services within a single calendar year (January 1 to December 31).

Once a family’s qualifying out-of-pocket expenses reach their specific cap amount for the year, TRICARE steps in to pay 100% of the TRICARE-allowable charges for most covered services for the remainder of that calendar year. The cap resets to $0 every January 1st.

What Counts Towards Reaching the Cap?

Understanding which expenses accumulate towards the catastrophic cap is vital for financial planning. The following out-of-pocket costs generally apply:

• Annual Enrollment Fees: Specifically, the annual fees paid by retirees and their families for TRICARE Prime and TRICARE Select enrollment.
• Annual Deductibles: The amount paid before cost-sharing begins in plans like TRICARE Select, TRS, TRR, TYA-Select, and for non-Medicare covered services under TFL.
• Copayments: Fixed dollar amounts paid for healthcare services and prescriptions (at home delivery or retail pharmacies).
• Cost-Shares: Percentage-based payments for covered services based on TRICARE-allowable charges.

What Does NOT Count Towards the Cap?

Equally important is knowing which expenses do not contribute to reaching the catastrophic cap. These include:

• Monthly Premiums: Payments required for TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), and the Continued Health Care Benefit Program (CHCBP).
• TRICARE Prime Point-of-Service (POS) Charges: Both the separate POS deductible and the 50% cost-share incurred for non-referred care under Prime.
• Charges Above the TRICARE Allowable Amount: This includes the extra amount (up to 15%) that non-participating providers may balance bill beneficiaries.
• Costs for Non-Covered Services: Any payments made for services or supplies that TRICARE does not cover.
• Payments from Other Health Insurance: Amounts covered or reimbursed by other insurance policies.

The exclusion of certain costs, particularly monthly premiums and POS charges, is significant. Beneficiaries enrolled in premium-based plans continue to pay their monthly premiums even after reaching their catastrophic cap. Similarly, those using the POS option under Prime can incur substantial costs that are entirely separate from the cap protection.

Catastrophic Cap Amounts for CY 2025

The catastrophic cap amount itself varies significantly depending on the beneficiary’s plan, status (ADFM vs. Retiree/Other), and Group (A or B).

Table 4: TRICARE Catastrophic Caps (CY 2025)

¹ The cap is $3,000 for Group A retirees who are survivors of ADSMs or are medically retired sponsors/dependents enrolled in Select. ² CHCBP cap depends on sponsor’s status prior to enrollment; $1,288 if former active duty, $4,509 if former retiree. Table uses higher value as baseline.

Tracking Progress and Plan Changes

Beneficiaries can monitor their accumulated out-of-pocket expenses counting towards the catastrophic cap by reviewing their TRICARE Explanation of Benefits (EOB) statements, which are provided after claims are processed. The EOB details how much of the payment for that specific claim applied towards the cap and the total accumulated amount for the calendar year to date.

If a beneficiary changes TRICARE plans mid-year under the same sponsor, any amount already credited towards the catastrophic cap under the old plan will typically be credited towards the cap under the new plan. If the sponsor’s status changes during the year (e.g., from Active Duty to Retired), the family’s accumulated out-of-pocket expenses will then count towards the catastrophic cap associated with the new status.

For example, if an active duty family (Group A, $1,000 cap) met $300 of their cap and then the sponsor retired mid-year, enrolling the family in TRICARE Select (Group A Retiree, $4,261 cap), they would have $3,961 ($4,261 – $300) remaining to meet towards their new retiree cap for that calendar year.

For definitive information on the Catastrophic Cap, refer to the official TRICARE page: TRICARE Catastrophic Cap.

Finding Official Information and Tools

Navigating TRICARE costs requires access to accurate, current information. The official TRICARE website, https://tricare.mil, serves as the primary and most reliable source. Costs and program rules can change, often annually, so consulting official resources regularly is recommended.

Here are direct links to key resources on the TRICARE website:

• General Costs Overview
• Compare Costs Tool (Detailed cost comparisons for different plans and beneficiary groups)
• Plan Finder Tool (Helps determine eligible plan options based on individual circumstances)
• Cost Terms Glossary (Official definitions of key cost terminology)
• Catastrophic Cap Details (Specifics on cap amounts and what counts towards it)
• Pharmacy Program Information (Overview Fact Sheet)
• TRICARE Formulary Search Tool (Check medication coverage and tier)
• Find a Doctor/Provider Tool (Locate network providers)
• Costs and Fees Fact Sheet (CY 2025) or Preview (Consolidated cost information)
• Publications Page (Access to handbooks, fact sheets, and brochures)

Regional Contractor Contacts: For specific questions about claims, referrals, or local networks:

• TRICARE East Region (Humana Military): https://www.humanamilitary.com/ or 1-800-444-5445
• TRICARE West Region (TriWest Healthcare Alliance): https://tricare.mil/west or 1-888-TRIWEST (874-9378)

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