Dd Form 2876 - Tricare Prime Enrollment Application And Pcm Change Page 2
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8TRICARE PRIME ENROLLMENT APPLICATION AND PCM CHANGE FORM
This form is for the following:
- Eligible beneficiaries who want to enroll in TRICARE Prime, TRICARE Prime Remote (TPR),
or US Family Health Plan.
- Portability transfers to a new region for the TRICARE program listed above.
- Address changes within the same region for the TRICARE program listed above.
- Primary Care Manager (PCM) changes as follows: Within the same Military Treatment
Facility (MTF)/Clinic, to an MTF/Clinic, or to a civilian PCM.
Review the eligible categories (1 through 5) below to determine the application sections you
must complete.
SECTION
SECTION
SECTION
SECTION
SECTION
SECTION
I
II
III
IV
V
VI
ELIGIBLE CATEGORIES
Sponsor
Enrolling
Other
Reason
Enrollment
Information
Family
Health
for PCM
Signature
Fee
Members
Insurance
Change
Payment
1. Active Duty Members,
Complete
Reserve Component
if
X
Members called or ordered
changing
to active duty for 30 days
PCM
or more.
2. Active Duty Family
Complete
Members (ADFMs) and
if
X
X
X
X
Survivors of Active Duty
changing
(first three years in
PCM
survivor status).
3. Active Duty Family
Complete
Members of Reserve
Component Members
if
X
X
X
X
called or ordered to active
changing
duty for 31 days or more.
PCM
Must be eligible in DEERS.
4. Retirees, retiree family members,
survivors, and eligible former
X
spouses under 65 years of age
Complete
(Must
who reside within the 50 United
if
X
X
X
X
States or the District of
include
changing
Columbia. This excludes
required
PCM
beneficiaries over the age of 65
payment)
who are eligible for TRICARE
Prime.
5. ADFMs, Retirees, retired
X
family members, survivors
Complete
(If not
and eligible former spouses
if
X
X
X
X
65 years or older and
enrolled in
changing
entitled to Medicare Part
Medicare
PCM
A. (Applicable only to US
Part B)
Family Health Plan.)
DD FORM 2876, MAR 2004
Page 2 of 8 Pages
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