Dd Form 2876 - Tricare Prime Enrollment Application And Primary Care Manager (Pcm) Change Page 2
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7GENERAL INSTRUCTIONS
1. TRICARE Prime - Active duty service members are required to enroll in Prime. Active duty family members,
retirees and their family members are encouraged, but not required, to enroll in Prime. Please note that enrollment
is not automatic.
2. TRICARE Prime Remote (TPR) is a program for active duty service members and their family members when
the sponsor lives and works over 50 miles or one hour drive from a Military Treatment Facility (MTF) and the family
member lives with the sponsor. Note: If residing in a Prime Service area, family members wishing to enroll must
choose Prime and not TPR ADFM.
3. US Family Health Plan is a TRICARE Prime enrollment option for eligible individuals and families who live in six
specific parts of the country: Seattle, Washington; Portland, Maine; Boston, Massachusetts; Staten Island, New
York; Baltimore, Maryland; and Houston, Texas. The primary difference between other TRICARE options and the
US Family Health Plan is that US Family Health Plan may be used by uniformed service retirees and their eligible
family members who are age 65 or older.
For enrollment or PCM changes in the US Family Health Plan, submit the completed Application/PCM Change
Form to the US Family Health Plan address listed below. For questions regarding enrollment/PCM changes in the
US Family Health Plan, contact the US Family Health Plan member services at:
ME and NH
MD, PA, VA and WV
MA and RI
NY, NJ, PA and CT
US Family Health Plan
US Family Health Plan
US Family Health Plan
US Family Health Plan
Martin's Point Health Care
Johns Hopkins Medicine
at Brighton Marine
at St. Vincent NYC
PO Box 9746
PO Box 815
Po Box 9195
450 West 33rd St, 12th Floor
Portland, ME 04104-5040
Glen Burnie, MD 21060
Watertown, MA 02471-9900
New York, NY 10001
888-241-4556
800-801-9322
800-818-8589
800-241-4848
4. If enrolling more than three family members, fill out additional copies of Page 5.
5. Print in blue or black ink; make sure all available information is complete, accurate and legible.
6. Make sure all personal information matches that in the Defense Enrollment Eligibility Reporting System
(DEERS). To check your DEERS information, call the Support Office at 1-800-538-9552 or log on to
and refer to your name as printed on your military ID card.
7. If you are an unremarried former spouse, make sure you show in DEERS under your own Social Security
Number and use your own SSN as the "Sponsor Social Security Number" on the enrollment form (block 1).
8. If you become Medicare-eligible, for any reason, make sure your Medicare Part A and B status is correctly
reflected in DEERS (Part B is required for all TRICARE beneficiaries, other than active duty family members.
Though Part B is not required for US Family Health Plan enrollees, the Department of Defense highly encourages
enrollment in Part B when first eligible to avoid potential Medicare Part B surcharges for enrollment.)
9. Sign and date the application (Section VI).
10. Please keep a copy of the completed TRICARE Prime Application/PCM Change Form for your records.
Enrollment in TRICARE Prime requires that all services, except for emergencies, must be coordinated
through the PCM. If not, the beneficiary will be responsible for payment of charges in accordance with the
Point-of-Service (POS) option as described in the TRICARE Beneficiary Handbook.
Page 2 of 7 Pages
DD FORM 2876, FEB 2011
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