Mosaic Pharmacy Enrollment

You're only minutes away from completing online enrollment

Please confirm the information below and provide some additional information about how we can reach you. If you are completing this form for someone else, please confirm you have their permission. We’ll use this information to follow up about next steps.
All fields marked with an asterisk (*) are required
Patient Name

First NameLast Name
Confirmation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What type of phone number is this?
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Location

Street Address

Street Address Line 2

CityState

Zip Code

Unfortunately, we currently are not able to fill prescriptions within your state. Please call 800-510-5989 if your location changes or you may submit the information you have entered so far and if we expand coverage to your location, we will reach out to you.
 

By pressing submit, you are providing consent for us to use your email and phone number for Mosaic to reach out relating to future Mosaic opportunities. If you elect to submit your contact information, you can opt out by providing notice to us. Please read our privacy policy and notice of privacy practices for more information.

If you don't wish to submit your contact information, please click back or navigate away from this page.

We protect and encrypt your data.

Your Health Coverage

Tell us about your Medicare and prescription drug coverage. We use this information to check whether Mosaic works with your health plan.
Do you have Medicare Part D Drug coverage?
Please select your insurance plan. If you don't see your plan on this list, select other.
Please enter the name of your insurance plan.
Insurance DQ Flag
Do you have secondary coverage?

Unfortunately, our services are currently only available to certain Medicaid patients in Virginia and Pennsylvania. If you live in one of these states, please call 800-510-5989 to see if you qualify. Or you may submit the information you have entered so far and you will receive a phone call from our Mosaic team at (800) 510-5989.

By pressing submit, you are providing consent for us to use your email and phone number for Mosaic to reach out relating to future Mosaic opportunities. If you elect to submit your contact information, you can opt out by providing notice to us. Please read our privacy policy and notice of privacy practices for more information.

If you don't wish to submit your contact information, please click back or navigate away from this page.
Unfortunately, based on your current plan, Mosaic is not available to you right now. If anything changes with your coverage, please don't hesitate to call us at 800-510-5989.

By pressing submit, you are providing consent for us to use your email and phone number for Mosaic to reach out relating to future Mosaic opportunities. If you elect to submit your contact information, you can opt out by providing notice to us. Please read our privacy policy and notice of privacy practices for more information.

If you don't wish to submit your contact information, please click back or navigate away from this page.
Unfortunately, we are currently only accepting patients who have Medicare. If anything changes with you coverage, please feel free to reach back out at 800-510-5989.

By pressing submit, you are providing consent for us to use your email and phone number for Mosaic to reach out relating to future Mosaic opportunities. If you elect to submit your contact information, you can opt out by providing notice to us. Please read our privacy policy and notice of privacy practices for more information.

If you don't wish to submit your contact information, please click back or navigate away from this page.

Mosaic Pharmacy Service is a long-term care pharmacy services provider for members of certain Medicare Part D plans who need long-term care pharmacy services at home. Based on your current situation, you do not qualify for Mosaic Pharmacy Service. If anything changes or you want to discuss your situation with someone, please call us at 800-510-5989.

By pressing submit, you are providing consent for us to use your email and phone number for Mosaic to reach out relating to future Mosaic opportunities. If you elect to submit your contact information, you can opt out by providing notice to us. Please read our privacy policy and notice of privacy practices for more information.

If you don't wish to submit your contact information, please click back or navigate away from this page.

Let's continue by learning more about you

The next step is to collect more information to help Mosaic better serve you (what medications you take, mailing address to send meds, etc.). You can provide this by continuing with online enrollment or you can ask a friendly Mosaic team member to give you a call.

By selecting to complete the enrollment form now, you agree to let us contact your (or the patient's) healthcare provider, and you acknowledge our notice of privacy practices and notice of privacy practices.
How would you like to continue?

We'll give you a call

Click Submit below to send the information you’ve provided. A Mosaic team member will contact you at the phone number you entered.

If you would like immediate assistance, call our pharmacy at (800) 510-5989. We look forward to speaking with you!

By clicking submit, you are providing consent to the use of the information in connection with the evaluation of enrollment in Mosaic Pharmacy Services. You will receive an outreach from our Mosaic team at (800) 510-5989.

About You

Please provide your basic information and the name of someone we can contact in an emergency. This helps us confirm your identity and know who to contact if needed.
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact

First NameLast Name
Relationship to Patient
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Caregiver or Support Person

If someone helps you manage your medications or healthcare, please tell us about them. With your permission, Mosaic can include this person when helping with your pharmacy needs.
Do you have a caregiver?
Do you give this individual permission to discuss your medications, check your order status, and answer questions about shipping and paying for your medications
Use my emergency contact information for my caregiver
Caregiver Name

First NameLast Name
Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Mosaic may require additional information at enrollment in order to validate Caregiver's authority.

Your Prescription Coverage
Please upload a photo of the front and back of your insurance card. If you don't have your card on you, you can manually enter the information below.

We'll use this information to confirm your coverage.
Click in the box below to upload images of the front and back of your card. Accepted file types: PDF, DOC, DOCX, ZIP, JPG, JPEG, PNG, HTML

Cancelof
Member ID
Rx BIN
Rx PCN
Rx GRP

Your Healthcare Providers and Pharmacies

If you know this information, please list the healthcare providers involved in your care and the pharmacies you currently use. This helps Mosaic confirm your medications and coordinate your care if you enroll.

This page is optional. You may leave it blank and click Next if you do not have this information.

Please list your healthcare providers below

Rows	Provider Name	Specialty	Phone Number	Address
Healthcare Provider #1
Healthcare Provider #2
Healthcare Provider #3
Healthcare Provider #4

Please list your pharmacies below

Rows	Pharmacy Name	Phone Number	Address
Pharmacy #1
Pharmacy #2
Pharmacy #3
Pharmacy #4

Tell us about your medications

You can share your medications by uploading photos of the label on each bottle or entering them below. This helps Mosaic understand your pharmacy needs and make sure your medication information is complete and accurate.

Sharing your medications is optional. You may choose not to provide this information at this time.
Would you like to share your medications?
Please upload clear photos of your medicine bottles, packages, or current medicine list. Click the box below to add your photos. Make sure each photo clearly shows: medicine name, strength, directions. Include all prescription medicines, over-the-counter medicines, vitamins, and supplements. Tips for taking clear photos: place medicines on a flat surface, use good lighting, take more than one photo if needed, make sure labels are not blurry or cut off. Accepted file types: PDF, DOC, DOCX, ZIP, JPG, JPEG, PNG, HTML

Cancelof
Please list your medications. Enter any medications you would like to share, including prescription medications, over-the-counter medicines, vitamins, and supplements. Include the medication name, strength or dose, and how often you take it, if you know. If you are unsure about any details, enter what you can.
UTM Source
UTM Medium
UTM Campaign
UTM ID
fbclid
By clicking submit, you are providing consent to the use of the information in connection with the evaluation of enrollment in Mosaic Pharmacy Services. You will receive an outreach from our Mosaic team at (800) 510-5989.
Should be Empty:

Please upload a photo of the front and back of your insurance card. If you don't have your card on you, you can manually enter the information below.