TRICARE Cost Sharing: Copays, Deductibles, and Caps Explained

*Note: TRICARE.com is an independent reference site and is not the official TRICARE program or affiliated with the Department of Defense. For official policy, visit TRICARE.mil.*

## Quick answer Cost sharing in TRICARE refers to the portion of a medical bill you pay out of your own pocket. This typically includes annual deductibles, fixed copayments for visits, and "cost-shares," which are a percentage of the total allowed amount for a service (e.g., paying 20% of a specialist bill).

Details

Cost sharing is the mechanism TRICARE uses to split healthcare expenses between the government and the beneficiary. The amount you pay depends heavily on two factors: your **beneficiary category** (Group A vs. Group B) and your **TRICARE plan** (Prime vs. Select).

### 1. Deductibles Before TRICARE begins paying for most services, you must meet an annual deductible. * **TRICARE Prime:** Active duty service members and their families generally have $0 deductibles. * **TRICARE Select:** For 2026, deductibles vary based on the sponsor's rank and beneficiary group. For example, a Group B retiree family may have a significantly higher deductible than an E-4 active duty family.

### 2. Copayments vs. Cost-Shares * **Copayments:** These are fixed dollar amounts you pay for specific services. For example, in 2026, a retiree on TRICARE Prime might pay a flat $38 copay for a generic primary care visit at a network provider. * **Cost-Shares:** This is a percentage of the total cost. This is more common in TRICARE Select or when using TRICARE Prime's Point-of-Service (POS) option. For instance, you might be responsible for 20% of the "allowable charge" for an outpatient surgery, while TRICARE pays the remaining 80%.

### 3. The Catastrophic Cap The "Catastrophic Cap" is the most important protection in TRICARE cost sharing. It is the maximum amount you will pay out-of-pocket for covered services each calendar year. * Once you hit this limit (which includes deductibles, copays, and enrollment fees), TRICARE pays 100% of the allowed amount for covered services for the rest of the year. * *Note:* The cap does not include Point-of-Service fees or premiums for plans like TRICARE Reserve Select.

### 4. Group A vs. Group B * **Group A:** Sponsors whose initial enlistment or appointment was before January 1, 2018. * **Group B:** Sponsors whose initial enlistment or appointment was on or after January 1, 2018. Group B generally has higher enrollment fees but different cost-share structures.

### 5. Point-of-Service (POS) Charges If you are enrolled in TRICARE Prime and see a provider without a referral (excluding emergency care), you trigger "Point-of-Service" charges. This is the most expensive form of cost sharing, often involving a $300 individual deductible and a 50% cost-share of the bill.

## Who this affects * **Active Duty Family Members (ADFMs):** Usually face the lowest cost-sharing, often $0 when using Prime. * **Retirees and their Families:** Subject to higher enrollment fees, copays, and deductibles than active duty families. * **National Guard and Reserve:** Those using TRICARE Reserve Select (TRS) or TRICARE Retired Reserve (TRR) have specific monthly premiums and cost-shares. * **Survivors:** Generally treated as active duty family members for the first three years, then transition to retiree-rate cost sharing.

## Sources * **TRICARE.mil:** [Cost Terms](https://www.tricare.mil/Costs/Cost-Terms) * **Defense Health Agency (DHA):** [TRICARE Costs and Fees 2026](https://www.tricare.mil/costs) * **TriWest Healthcare Alliance (West Region):** [Understanding Costs](https://www.triwest.com) * **Humana Military (East Region):** [Beneficiary Costs](https://www.humanamilitary.com)