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DD Form 2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
What Is the DD Form 2876-2?
DD Form 2876-2 , TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form, is a form is used to gather the information required enrolling or disenrolling individuals in TRICARE Prime, TRICARE Prime Remote, or Uniformed ServicesFamily Health Plan - specifically within the Western Region of the United States.
The form is a part of a series of TRICARE-related forms issued by the Department of Defense (DoD) on July 1, 2016 .
DD Form 2876-2 along with DD Form 2876-1, DD Form 2876-3, and the universal DD Form 2876 are all referred to as the TRICARE Prime Form DD 2876 for short. An up-to-date DD Form 2876-2 fillable copy is available for filing or download below or can be found on the Executive Services Directorate website.
DD Form 2876-2 Instructions
TRICARE Prime enrollment is available only to those registered in DEERS (Defense Enrollment Eligibility Reporting System). TRICARE Prime enrollment is available year-round. Get in touch with your regional contractor directly through the TRICARE web page or by filling and submitting the DD 2876-2 Form.
Filling out DD 2876-2 is self-explanatory. Applicants must choose the applicable TRICARE coverage option out of the various payment options provided. All individuals filing must then provide their personal identifying data and information about their relatives as well as their addresses and sponsor information. Applicants enrolling in TRICARE must disclose any information regarding any other health insurance they have at the time of filing.
Prime enrollment applications received on or before the 20th of each month are effective the first calendar day of the next one. All applicants except for active dutyservice members or those enrolling in TRICARE Overseas Prime or must confirm enrollment and PCM assignment before obtaining medical care.
The TRICARE Regional Contractor Address for the Western Region of the United States is at the Health Net Federal Services, PO Box 8458, Virginia Beach, VA 23450-8458 .
Download DD Form 2876-2 TRICARE Prime Enrollment, Disenrollment, and Primary Care Manager (PCM) Change Form
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