2022 Member Forms

Enrollment Forms:

Medical benefits:

Pharmacy benefits (including Part D vaccines):

Dental Reimbursement form:

Prescription Drug Forms:

Billing Form:

Representative Forms:

Privacy Form:

Harvard Pilgrim is an HMO/HMO-POS plan with a Medicare contract. Enrollment in StrideSM (HMO) depends on contract renewal.

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H6750_22139                                                        Last Update: 10/01/2021