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Back left Back right Front left Front right. Blue Shield of California. Subscriber JOHN DOE. a b c d

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Sample ID card and description of terms

Back left

This information is used by physicians and providers.

Back right

Member services numbers and addresses to submit claims.

Front left

a

Member name – your name

b

Member ID number

c

PCP/SPC – indicates the primary care

physician (PCP)/ specialist (SPC) office visit copays

d

ER – indicates emergency room

(ER) copay

Front right

e

Group# and Plan – shows type of

coverage

f

Effective date – the date you became

covered by our plan

g

This information is required by

pharmacies to electronically bill prescriptions.

Back left

Back right

Front left

Front right

Providers: Please file all claims with your local BlueCross BlueShield licensee in whose service area the member received services or, when Medicare is primary, file all Medicare claims with Medicare.

California Providers: Call Provider Customer Service to obtain medical and hospital admission prior authorization to avoid reduced or non-payment; Pharmacistscall for prescription processing information. Visit Provider Connection at:

blueshieldca.com/provider.

CA Medical claims to:

Blue Shield of California, P.O. Box 272540, Chico, CA 95927-2540

(800) 642-6155 Member Services

(800) 241-1823 TTY

(877) 263-9952 Mental Health Customer Svc.

(877) 304-0504 NurseHelp 24/7

(800) 985-2405 LifeReferrals 24/7

(800) 810-2583 To locate providers outside of California

(800) 541-6652 CA Provider Customer Service (including hospitals)

(888) 635-8224 Pharmacists Only Blue Shield of California is an independent member of the Blue Shield Association.

Subscriber JOHN DOE ID# XEHJ02388023 Copayments Office $25 Hospital $200 Emergency $100 Group # H12187 Effective 01/01/13 Plan HMO Rx Yes blueshieldca.com

SF HEALTH SERVICE SYSTEM Blue Shield of California

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en d en t M em b er o f t h e B lu e S h ie ld A ssoc ia tio n A 4 576 0 ( 4/ 13 )

Inside left

j

Name of your Personal Physician

k

Name of your medical group or IPA

Inside right

This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies.

MEDICAL GROUP NAME JANE DOE, MD (415) 123-4567 JOHN DOE Effective 01/01/13 JOHN DOE, JR. Effective 01/01/13

A+ gives you the option to self-refer to an Access+ Specialist, subject to certain limitations.

See your Evidence of Coverage for details.

Members:

In case of emergency, call 911 or seek appropriate emergency care. As soon as possible after receiving care, please contact your personal Physician.

It is important to follow the procedures explained in your

Evidence of Coverage booklet. If you have any questions about your benefits, your copayments,or your prescription drug coverage, call Member Services.

Carry this ID card with you at all times and present it to your Personal Physicianwhenever you receive care.

(3)

Sample ID card and description of terms

Back left

This information is used by physicians and providers.

Back right

Member services numbers and addresses to submit claims.

i

Address for you to send out-of-network

prescription claims to

Front left

a

Member name – your name

b

Member ID number

c

PCP/SPC – indicates the primary care

physician (PCP)/ specialist (SPC) office visit copays

Note: Refer to your Evidence of Coverage for complete benefit information. The information provided on your ID card is to be used as a quick reference only. Benefits are not limited to this information.

d

ER – indicates emergency room

(ER) copay

e

AMB – indicates ambulance

(AMB) copay

Front right

f

Group No. and Plan – shows type

of coverage

g

Card issued – the date your most recent

card was issued to you

h

This information is used by pharmacies to

electronically bill prescriptions.

Copayments

PCP/SPC $XX/XX

ER $XXX

AMB $XXX

PhysiCians and Providers: Prior approval: Telephone the physician named on this card prior to treatment in a non-emergency. Provision of routine treatment without prior authorization may result in non-payment.

emergency care: Telephone the physician named on this card as soon as possible after treatment.

note: This card is for identification only. Call the number on the reverse side of this card to verify eligibility.

PhysiCians and Providers:

(877) 654-6500elibility verification Blue Shield of California is an independent member of the Blue Shield Association.

<plan name> (HMO) Member Services

(800) 776-4466 (800) 794-1099TTY Note: This card is for identification only.

submit Medical claims to: Blue Shield 65 Plus P.O. Box 272640 Chico, CA 95927-2640

submit rx claims to:

Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168 RxBin 012353 RxPCN 01920000 Issuer 80840 CMS H0504-015

Plan <plan name> (hMo)

Group No. Mrd100 Card issued 12/1/12 Plan code Bs1 Member John doe Membership number XeaJ1234567801 blueshieldca.com

a

c

f

h

d

e

i

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Back left

Back right

Front left

Front right

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en d en t m em b er o f th e B lu e S h ie ld A ssoc ia tio n A 35 13 8 (1 0/ 12 )

Inside left

j

Name of your primary care physician

k

Name of your medical group or

Independent Practice Association (IPA)

l

Hospital name and address

Inside right

This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies.

j

k

l

John doe, Md (555) 555-5555 ABC Medical Grp 123 Main St Anytown, CA 00000 HOSPITAl INFORMATION: aBC hospital (555) 555-5555 123 Main St Address line 2 Anytown, CA 00000 (877) 304-0504 NurseHelp 24/7 (800) 855-2881 TTY in an emergency: Call 911 or immediately go to the nearest hospital emergency room for treatment.

out-of-area urgent care: If you are outside the health plan area and need medical attention right away for an unforeseen illness or injury, go to the nearest medical facility. Notify Blue Shield 65 Plus or your primary care physician at the time of service or as soon as possible after treatment.

Billing and member services:

Network providers have agreed not to bill Blue Shield 65 Plus members. Contact Member Services if you are billed in error or if you need other assistance with claims or billing.

For information on locating network pharmacies: Call Blue Shield 65 Plus Member Services.

(5)

Sample ID card and description of terms

Front

a

Member name – your name

b

Member ID number

c

Card issued – the date your most recent

card was issued to you

d

This information is used by pharmacies

to electronically bill prescriptions.

Back

e

Address for you to send out-of-network

prescription claims to

f

Member Services toll-free number

Front

Back

A n in d ep en d en t m em b er o f th e B lu e S h ie ld A ssoc ia tio n A 35 14 5 (1 0/ 12 ) blueshieldca.com RxBin 012353 RxPCN 03510000 RxGrp MRD300 Issuer 80840 CMS S2468-004

Plan <plan name> (PDP)

Card issued 12/15/12

Member

John Doe

Membership No.

XEAJ1234567801

Blue Shield of California is an independent member of the Blue Shield Association.

<plan name> (PDP) Member Services

(888) 239-6469Member Services

(888) 239-6482 TTY

Submit Rx claims to:

Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168

a

c

d

e

f

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