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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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