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TRICARE Reserve Select & TRICARE Retired Reserve

Reserve Component Health Coverage Request Form (DD Form 2896-1)

  1. Log on to the DMDC Reserve Component Purchased TRICARE Application
  2. Select "Purchase Coverage" and follow the instructions.
  3. Print and sign the completed Reserve Component Health Coverage Request Form (DD Form 2896-1). 

To log into the DMDC Reserve Component Purchased TRICARE Application, you must have one of the following:

The DS Logon Premium (Level 2) account is given to a user who has registered using their CAC, DFAS myPay Login ID, or has a DS Logon Basic Account. Sign up or view information regarding a DS Logon.

If you do not qualify, you will not be able to complete or print the form. Please contact your National Guard or Reserve personnel office for assistance. If you experience a technical problem, call 1-800-477-8227 for assistance. 

Submit the completed application to your regional contractor at the address listed below:

TRICARE Reserve Select  TRICARE Retired Reserve
North 

Health Net Federal Services, LLC
TRICARE Reserve Select Enrollment
P.O. Box 105402
Atlanta, GA 30348-5402

Fax: 1-888-299-4114

Health Net Federal Services, LLC
TRICARE Retired Reserve Enrollment
P.O. Box 105402
Atlanta, GA 30348-5402

Fax: 1-888-299-4114

South

Humana Military
ATTN: PNC Bank
P.O. Box 105389
Atlanta, GA 30348-5389

Fax: 1-866-836-9535

Humana Military
ATTN:  PNC Bank
P.O. Box 105389
Atlanta, GA 30348-5389

Fax: 1-866-836-9535

West

UnitedHealthcare Military & Veterans
TRICARE West Region Enrollment Department
P.O. Box 105492
Atlanta, GA 30348-5492

Fax: 1-877-890-7297

UnitedHealthcare Military & Veterans
TRICARE West Region Enrollment Department
P.O. Box 105492
Atlanta, GA 30348-5492

Fax: 1-877-890-7297

Overseas 

International SOS Assistance, Inc.
TOP TRS Enrollments
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1-215-354-5015

International SOS Assistance, Inc.
TOP TRR Enrollments
P.O. Box 11689
Philadelphia, PA 19116

Fax: +1-215-354-5015

Last Updated 5/28/2014