East Region

Automatic Credit/Debit Card Charge

Use this form to establish automatic payments on your credit or debit card. You can use it for:

• Enrollment fees for TRICARE Prime
• Monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve or TRICARE Young Adult.

Submit this completed form to the address or fax number on the form.

Set Up Automatic Payments With Allotment

TRICARE Prime and TRICARE Select beneficiaries should use this form to start, change, or stop automatic deduction of enrollment fees from their military retirement pay.

You can complete this form online.

Monthly Automatic Electronic Funds Transfer From Checking or Savings Account

Use this form to set up automatic payments using an electronic funds transfer for:

• Enrollment fees for TRICARE Prime or TRICARE Select
• Monthly premium payments for TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult

You can complete this form online.