Pharmacy benefits (including Part D vaccines):
Dental Reimbursement form:
Prescription Drug Forms:
- Part D (Pharmacy) Coverage Determination Request Form
- Part D Redetermination Request Form
- Medicare Part D Reconsideration Form (pdf)
- OptumRx Home Delivery Prescription Drug Order Form (pdf)
- Designation of Representative Form (pdf)
- CMS Appointment of Representative form (pdf)
- Personal Representative Cover Form (pdf)
Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in StrideSM (HMO) depends on contract renewal.
Links on this page may take you away from the Harvard Pilgrim Health Care website.
H6750_22139 Last Update: 10/01/2021