2024 plan documents and other information

Harvard Pilgrim Stride^SM (HMO) / (HMO-POS) member ID card samples are shown below:

View or download PDFs of Summary of Benefits, Evidence of Coverage, Provider and Pharmacy Directories and more.

Summary of Benefits (SB)
This booklet provides a summary of plan benefits and coverage.

• New Hampshire Summary of Benefits Last updated 10/2023

Evidence of Coverage (EOC)
This document is part of your contract with us and it provides detailed information about your benefits and how to use the plan.

• Stride^SM Basic Rx (HMO) Last updated 10/2023
• Stride^SM Value Rx (HMO) Last updated 10/2023
• Stride^SM Value Rx Plus (HMO) Last updated 10/2023
• Stride^SM Choice Rx (HMO-POS) Last updated 10/2023

Addenda

• Dental Addendum
• Transportation Addendum
• Wallet Benefit Addendum

Annual Notice of Changes (ANOC)
This document explains the changes effective January 1, 2024.

• Stride^SM Basic Rx (HMO) Last updated 10/2023
• Stride^SM Value Rx (HMO) Last updated 10/2023
• Stride^SM Value Rx Plus (HMO) – Strafford Last updated 10/2023
• Stride^SM Value Rx Plus (HMO) – All Other Counties Last updated 10/2023
• Stride^SM Choice Rx (HMO-POS) Last updated 10/2023

Additional Information

• Over-the-Counter Brochure
• Step Therapy for Medicare Part B Prescription Drugs
• Multi-language Insert
• 2024 Star Ratings for Harvard Pilgrim Health Care of New England – NH plans

Safeguarding Your Privacy

• Member Notice of Privacy Practices (pdf)
• Centers for Medicare & Medicaid (CMS) Appointment of Representative form (AOR) (pdf)
  Use this (CMS) form to authorize a friend, relative or other individual to make a request on your behalf (Organization Determination, Coverage Determination, Appeal or Grievance).
• Designation of Representation Form (pdf)
  Use this form to give our Member Services representatives the right to speak with another individual about your plan. We may also accept other legal documents you may have like a Power of Attorney, Guardianship or Health Care Proxy.
• Member Authorization Release Form (pdf)
  Use this form to allow a short term or one-time release of your health information to another individual or entity (for example, an attorney or another insurance company).

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

Links on this page may take you away from the Harvard Pilgrim Health Care website.

H6750_24007                                                 Last Update:1/1/2025