The DD Form 2814, also known as the Pharmacy Redesign Pilot Program Enrollment form, is issued by the Department of Defense for use by TRICARE beneficiaries. It collects the information needed to enroll a sponsor and family members in an enhanced pharmacy benefit through civilian pharmacy providers.
The form covers three main areas: sponsor identification (name, social security number, date of birth, and contact details), family member enrollment (each member's date of birth and relationship to the sponsor), and other health insurance disclosure along with payment method selection.
Disclosure on this form is voluntary. However, failure to provide accurate information may result in enrollment denial. This enrollment form is part of a broader set of TRICARE documents. Related forms include the TRICARE West EFT form for electronic funds transfer and the DD Form 2656 for retiree data verification.
Payment options include an annual payment and a semiannual payment per person per year. Retirees, retiree family members, and reserve component beneficiaries each have separate payment rates listed on page 3. Completing the payment section accurately is essential for processing your enrollment in the TRICARE Pharmacy Redesign Pilot Program.
| Question | Answer |
|---|---|
| Form Name | Dd Form 2814 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | dod-dd-2814, Okeechobee, TRICARE, 2000 |