2019 Member Forms
- Prescription Drug Mail Order Form (pdf)
- Part D (Pharmacy) Coverage Determination Request Form
- Prescription Drug Reimbursement (pdf)
- Electronic Funds Transfer (EFT) Form (pdf)
- Member Reimbursement Form (pdf)
- Designation of Representative form (pdf)
- CMS Appointment of Representative form (pdf)
Harvard Pilgrim is an HMO plan with a Medicare contract. Enrollment in Stride℠ (HMO) depends on contract renewal. This information is not a complete description of benefits. Call Member Services at 1-888-609-0692 for more information. TTY users, call 711.
Links on this page may take you away from the Harvard Pilgrim Health Care website.
|Y0098_19172||Last updated: 12/27/18|