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Enrollment – TRICARE Young Adult

TRICARE Young Adult Application

Use this form to enroll in or disenroll from the TRICARE Young Adult Program (Prime and Select options). For enrollment, your completed application must include the first two months of premium payments, paid by personal check, cashier's check, money order, or credit/debit card.

Send completed forms to: 

Health Net Federal Services, LLC
TYA Enrollment
PO Box 9028
Virginia Beach, VA 23450-9028
Fax: 1-844-388-8282

  • Created: Jan 8, 2020
  • Modified: Jan 8, 2020
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TRICARE Young Adult Electronic Funds Transfer or Recurring Credit Card Request Form

Use this form to change your TRICARE Young Adult automatic monthly payments.

  • Created: Dec 30, 2017
  • Modified: Dec 29, 2017
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Enrollment Exception Request

Complete this form to request an enrollment exception review.

  • Created: Jan 15, 2019
  • Modified: Jan 15, 2019
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Drive Time Waiver

A Drive Time Waiver must be signed by the beneficiary when the primary care manager (PCM) selected or assigned is farther than a 30-minute drive from the beneficiary's residence, or the beneficiary lives outside of a Prime Service Area. By completing this form, you are waiving the drive time standards of 30 minutes for primary care and one hour for specialty care. 

Send completed forms to: 

Health Net Federal Services, LLC
PO Box 8458
Virginia Beach, VA 23450-8458
Fax: 1-844-388-8282

  • Created: Jan 7, 2019
  • Modified: Jan 7, 2019
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