1. No category

Sample Health Net of California Medicare Advantage ID Card
your care.
emergency,
dialysis for
Coverage,
Health Net
Medicare Advantage HMO
1
Subscriber Name:
JOHN SAMPLE
KAREN
L BRANSON
2
Subscriber #: R01250356
RxProcessor: Caremark
RxBIN #: 004336
RxPCN #: ADV
RxGroup: RX6270
PG Eff. Date:
3
01-01-08
PPG #: 5044
10 copayment
7-735-2929)
4
7-735-2929)
Group # 00000F
Issuer: (80840)
CMS Contract H0562 068
*338190120000010002*
*338190120000010002*
9
5
6
7
10
8
Plan: 2T6 WITH PHARMACY RUBY
move card, fold back and forth along perforations.
11
Pharmacy Claims:
s:
s Welcome
Department
HealthYour
Net
of
California
Pharmacy
Claims:
dicare
Advantage
Claims Medical
to at
Health
Net.
benefit
information packet
will follow.
Claims:
.m to 8:00 15
Attn: Net
Pharmacy
Health
Medicare Advantage Claims Health Net of California
40512
P.O.
Attn:
Pharmacy
P.O.Box
Box14702
9103
Health
Net Use Only
Lexington,
Van Nuys,KY
CA40512
91409-9103
P.O.Run
BoxDate
9103
12/04/2007
Nuys,
- 1 CA 91409-9103
To The Health Net Medicare Advantage Member: This is Van58
18
N3
your current Health Net Identification card. Carry it with
ENG-MED-ADV-PARTD
you at all times, and present it to your Health Net
17E5
Medicare Advantage Participating Physician when you
receive services. See your Evidence of Coverage for a
Decisiondescription
Power Health
Coach,
call
1-800-893-5597
CAM CHIR
of your benefits. When submitting inquiries
-800-276-3821)
24 coverage,
hours
day,
7 days
a week
6-5610
Toa contact
ainclude
Decision
Health
call
1-800-893-5597
MHN
INST
M1
about16
your
always
yourPower
Subscriber
ID Coach,
(TTY/TDD: 1-800-276-3821) 24 hours a day, 7 days a week
number.
** No EOC
cy arises: Call 911 or go to the nearest hospital or
ALAMEDA
If an emergency
arises: Call
e facility. If 17
you are unsure
of the seriousness
of 911 or go toMthe nearest hospital or
emergency care facility. If you are unsure2T6
of the seriousness of
19
n, you may call your physician for assistance.
your condition, you may call your physician for assistance.
You have selected the following medical group for your care.
All medical services, with the exception of emergency,
urgently needed services, or out of the area renal dialysis for
ESRD members, as defined in your Evidence of Coverage,
must be provided or arranged by:
Group/Physician Name:
ABC PHYSICIANS
MEDICAL GROUP
HILL
- ABSMC
TIMOTHY
A FITZER
JOHN SAMPLE
2636
Telegraph
Ave.
123 MAIN
STREET
BERKELEY
CA12345-6789
94704-3322
ANY CITY, CA
Group Phone:
1-925-820-8300 (TTY/TDD: 1-877-735-2929)
1-916-733-3333
Physician Phone: 1-916-536-2500
1-510-841-1647 (TTY/TDD: 1-877-735-2929)
PG Eff. Date:
01-01-08
PPG #: 1316
10 copayment
7-735-2929)
7-735-2929)
Medicare Advantage HMO
Subscriber Name – Name of the policy holder
2
Subscriber
# – Health Net-assigned subscriber ID number
SUZANNE WALTERICH
3
Group
# 00480B
SubscriberInformation
#: R00213210– Pharmacy
Pharmacy
codes
required for
Issuer: (80840)
Part
D
online
prescription
claims
processing
RxProcessor: Caremark
Subscriber Name:
RxBIN #: 004336
CMS Contract H0562 009
4 Plan
– Health
Net Medicare
plan code
4
Code
– Health
Net Medicare
plan and
codecolor
and under
color
RxPCN
#: ADV
RxGroup:
which
the RX6270
member
is enrolled
under
which
the member
is enrolled
5
Group # – Health Net-assigned number that identifies
the
employer
Plan:
2U4 WITHgroup
PHARMACY RUBY
6
– Health
plan-unique
ID number
assigned
by theby
6 Issuer
Card Issuer
– Health
plan-unique
ID number
assigned
Centers
for Medicare
and and
Medicaid
Services
(CMS)
the Centers
for Medicare
Medicaid
Services
(CMS)
move card, fold back and forth along perforations.
CMS Contract # – Health plan-unique contract number
CMS information packet will follow.
Welcome to Healthassigned
Net. Yourby
benefit
7
Medicare Logo – Logo that identifies Part D prescription
Health Net Use Only
medication coverage (not applicable
members
Runto
Date
12/04/2007
52 - 2
To The Health Net
MedicareinAdvantage
Member:
This is
enrolled
Seniority
Plus Green)
N2
8
your current Health Net Identification card. Carry it with
ENG-MED-ADV-PARTD
you at all times, and present it to your Health Net
9
Name
– Name
of 17ED
the participating
9 Group/Physician
PPGParticipating
Name – Name
ofwhen
the
participating
physician group
Medicare Advantage
Physician
you
receive services.physician
See your
Evidence
of
Coverage
for is
a assigned
groupthe
(PPG)
to which
theCAM
member
(PPG)
to
which
member
CHIR is assigned
description of your benefits. When submitting inquiries
MHN INST M1
about your coverage, always include your Subscriber ID
SP+ CORE
of thePREVENTIVE
member’s(HN
number. 10 PCP Information – Name and address
DENTAL)
assigned primary care physician (PCP)
** No EOC
SAN FRANCISCO
M
2U4
14
Plan: 2T6 WI
your condition, y
your condition,
To
To remove
remove card,
card, fold
fold back
back and
and forth
forth along
along perforat
perforat
Identification (ID) Card
Health Net Components
1
RxProcessor
RxBIN #: 004
12RxPCN #: AD
RxGroup:
RX
13
To remove card, fold back and forth along pe
Material ID#
ID# H0562-07-0145
H0562-06-0322
CMS Approval
Approval (10/07)
(11/06)
To remove
back and forth along perforatio
You have selected the following medical group
for card,
your fold
care.
To remove
card, fold back and forth along perforat
All medical services, with the exception
of emergency,
urgently needed services, or out of the area renal dialysis for
ESRD members, as defined in your Evidence of Coverage,
Subscriber N
11 PPG/PCP
Telephone
must beContacts
provided or–arranged
by: numbers of the member’s
SUZANNE W
Group/Physician
assigned
PPG and Name:
PCP
BROWN AND TOLAND MEDICAL GROUP
Subscriber #
*338190120000040005*
emergency,
dialysis for
Coverage,
Subscriber #
For
For questions
questions or
or concerns,
concerns, call
call the
the Member
Member Services
Services Department
Department
Medical Claims:
Claims:
Medical
at
to
Health
Net
Comm
at 1-800-275-4737
1-800-275-4737 (TTY/TDD:
(TTY/TDD: 1-800-929-9955)
1-800-929-9955) 7:30
7:30 a.m.
a.m.
to
Welcome
to Health
Net.Net
Your
be
Health
Comm
For
questions
or
concerns,
call
the
Member
Services
Department
at
Medical
Claims:
12:00
p.m. and
andor1:00
1:00
p.m. to
tocall
5:00
p.m.,
Monday
through
Friday,
P.O. Box
Box 14702
14702
12:00
p.m.
p.m.
5:00
p.m.,
Monday
through
Friday,
For
questions
concerns,
the
Member
Services
Department
P.O.
Medical
Claims:
1-800-275-4737
(TTY/TDD:
1-800-929-9955)
8:00
a.m
to
8:00
Health
Net
Medica
except
holidays. (TTY/TDD: 1-800-929-9955) 7:30 a.m. to
Lexington, KY
KY 40
40
except
holidays.
Lexington,
at
1-800-275-4737
Health
Comm
p.m.,
7 days a week.
P.O.
BoxNet
14702
12:00
p.m. and
1:00 p.m.
to1-800-929-9224.
5:00 p.m., Monday through Friday,
P.O. Box 14702
For
Provider
inquiries,
call
Lexington,
KY
405
For
Provider
inquiries,
call
1-800-929-9224.
094893
For
Provider
inquiries, call 1-800-929-9224.
except
holidays.
KYAd
40
To The HealthLexington,
Net Medicare
00000F call 1-800-693-8951.
Pharmacists
Pharmacists
call
Pharmacists
call 1-888-865-6567.
1-800-693-8951.
your current Health Net Identific
ForKAREN
ProviderL.inquiries,
call
1-800-929-9224.
BRANSON
you at all times, and present it to
EUCLID
AVE
For1799
dental
benefits,
call Health
Health Net
Net Dental
Dental at
at 1-800-880-8113
1-800-880-8113
Medicare Advantage Participatin
For
dental
benefits,
call
Pharmacists
call 1-800-693-8951.
receive services.
See youra
APT 21
To contact
contact
aEvid
De
(TTY/TDD:1-800-880-3165)
To
De
(TTY/TDD:1-800-880-3165)
description of your
benefits. Wh
(TTY/TDD:
1-8
CA 94709
1263 Net
ForBERKELEY,
vision
benefits,
call Health
Health
Net Vision
at
1-866-392-6058
(TTY/TDD:
1-8
For
vision
call
at
dental benefits,
Dental
at 1-866-392-6058
1-800-880-8113
For
mental
health benefits,
call MHNVision
at 1-800-646-5610
To
contact
a Dec
about your coverage,
always
inc
(TTY/TDD:
1-866-308-5375)
(TTY/TDD:
1-866-308-5375)
To contact a1-80
De
(TTY/TDD:1-800-880-3165)
number.
(TTY/TDD:
(TTY/TDD:
1-800-327-0801)
For mental
mental
health
benefits
call,
MHN
at
1-800-646-5610
If
an
emergency
(TTY/TDD:
1-8
For
health
benefits
call,
MHN
at
1-800-646-5610
vision benefits, call Health Net Vision at 1-866-392-6058
If an emergency
(TTY/TDD: 1-800-327-0801)
1-800-327-0801)
care
(TTY/TDD:
1-866-308-5375)
emergency
care
Ifemergency
an emergency
your
condition,
Forchiropractic/acupuncture
mental
health benefits call
call,
MHN at 1-800-646-5610
If
an
emergency
For
1-800-678-9133
your
condition,
Material
ID#
H0562-06-0322
emergency
care
f
Material ID# H0562-06-0322
(TTY/TDD:
1-800-327-0801)
CMS
Approval1-877-710-2746)
(11/06)
(TTY/TDD:
emergency care
CMS
Approval
(11/06)
*338190120000040005*
ations.
your
ove
card,care.
fold back and forth along perforations.
PPG Eff. Date:
01-01-08
02-01-07
XXX
PPG #: 5044
15 copayment
PCP Copay: $10
Subscriber N
KAREN L BR
12 PPG Effective Date – Date the member was assigned
B BIRNBAUM
to GARY
the PPG
1580 Valencia St.
SAN
13 PPG
# –FRANCISCO
ID numberCA
for94110-4423
the PPG
PPG Eff. Date:
01-01-08
PPG #: 1316
PCP Copay: $10 copayment
RxProcessor
RxBIN #: 004
RxPCN #: AD
RxGroup: RX
14 PCP Copayment – Out-of-pocket expense the member is
Group Phone:
(TTY/TDD:
1-877-735-2929)
required
to pay for 1-415-972-6000
covered services
(copayments
vary
Physician Phone: 1-415-550-0811 (TTY/TDD: 1-877-735-2929)
by plan)
Plan: 2U4 W
15 Claims Information – Claims submission addresses
To remove card, fold back and forth along pe
16 Decision PowerSM – Contact information for health coaches
Welcome
to Health Net. Your be
17 Emergency Information – Instructions to member
on what
to do for an urgent or emergency health problem
028409
18 Important
Telephone Numbers – Health Net contactTo The Health Net Medicare Ad
00480B
telephone
numbers
SUZANNE
WALTERICH
64 BAYVIEW ST
19 Vendor
Contacts
– Contact
information
SAN
FRANCISCO,
CA 94124
2339
for
participating vendors administering certain
plan benefits
your current Health Net Identific
you at all times, and present it to
Medicare Advantage Participatin
receive services. See your Evid
description of your benefits. Wh
about your coverage, always inc
number.
Sample Health Net of California Medicare Advantage ID Card
your care.
emergency,
dialysis for
Coverage,
Health Net
Medicare Advantage HMO
1
Subscriber Name:
JOHN SAMPLE
KAREN
L BRANSON
2
Subscriber #: R01250356
RxProcessor: Caremark
RxBIN #: 004336
RxPCN #: ADV
RxGroup: RX6270
PG Eff. Date:
3
01-01-08
PPG #: 5044
10 copayment
7-735-2929)
4
7-735-2929)
Group # 00000F
Issuer: (80840)
CMS Contract H0562 068
*338190120000010002*
*338190120000010002*
9
5
6
7
10
8
Plan: 2T6 WITH PHARMACY RUBY
move card, fold back and forth along perforations.
11
Pharmacy Claims:
s:
s Welcome
Department
HealthYour
Net
of
California
Pharmacy
Claims:
dicare
Advantage
Claims Medical
to at
Health
Net.
benefit
information packet
will follow.
Claims:
.m to 8:00 15
Attn: Net
Pharmacy
Health
Medicare Advantage Claims Health Net of California
40512
P.O.
Attn:
Pharmacy
P.O.Box
Box14702
9103
Health
Net Use Only
Lexington,
Van Nuys,KY
CA40512
91409-9103
P.O.Run
BoxDate
9103
12/04/2007
Nuys,
- 1 CA 91409-9103
To The Health Net Medicare Advantage Member: This is Van58
18
N3
your current Health Net Identification card. Carry it with
ENG-MED-ADV-PARTD
you at all times, and present it to your Health Net
17E5
Medicare Advantage Participating Physician when you
receive services. See your Evidence of Coverage for a
Decisiondescription
Power Health
Coach,
call
1-800-893-5597
CAM CHIR
of your benefits. When submitting inquiries
-800-276-3821)
24 coverage,
hours
day,
7 days
a week
6-5610
Toa contact
ainclude
Decision
Health
call
1-800-893-5597
MHN
INST
M1
about16
your
always
yourPower
Subscriber
ID Coach,
(TTY/TDD: 1-800-276-3821) 24 hours a day, 7 days a week
number.
** No EOC
cy arises: Call 911 or go to the nearest hospital or
ALAMEDA
If an emergency
arises: Call
e facility. If 17
you are unsure
of the seriousness
of 911 or go toMthe nearest hospital or
emergency care facility. If you are unsure2T6
of the seriousness of
19
n, you may call your physician for assistance.
your condition, you may call your physician for assistance.
You have selected the following medical group for your care.
All medical services, with the exception of emergency,
urgently needed services, or out of the area renal dialysis for
ESRD members, as defined in your Evidence of Coverage,
must be provided or arranged by:
Group/Physician Name:
ABC PHYSICIANS
MEDICAL GROUP
HILL
- ABSMC
TIMOTHY
A FITZER
JOHN SAMPLE
2636
Telegraph
Ave.
123 MAIN
STREET
BERKELEY
CA12345-6789
94704-3322
ANY CITY, CA
Group Phone:
1-925-820-8300 (TTY/TDD: 1-877-735-2929)
1-916-733-3333
Physician Phone: 1-916-536-2500
1-510-841-1647 (TTY/TDD: 1-877-735-2929)
PG Eff. Date:
01-01-08
PPG #: 1316
10 copayment
7-735-2929)
7-735-2929)
Medicare Advantage HMO
Subscriber Name – Name of the policy holder
2
Subscriber
# – Health Net-assigned subscriber ID number
SUZANNE WALTERICH
3
Group
# 00480B
SubscriberInformation
#: R00213210– Pharmacy
Pharmacy
codes
required for
Issuer: (80840)
Part
D
online
prescription
claims
processing
RxProcessor: Caremark
Subscriber Name:
RxBIN #: 004336
CMS Contract H0562 009
4 Plan
– Health
Net Medicare
plan code
4
Code
– Health
Net Medicare
plan and
codecolor
and under
color
RxPCN
#: ADV
RxGroup:
which
the RX6270
member
is enrolled
under
which
the member
is enrolled
5
Group # – Health Net-assigned number that identifies
the
employer
Plan:
2U4 WITHgroup
PHARMACY RUBY
6
– Health
plan-unique
ID number
assigned
by theby
6 Issuer
Card Issuer
– Health
plan-unique
ID number
assigned
Centers
for Medicare
and and
Medicaid
Services
(CMS)
the Centers
for Medicare
Medicaid
Services
(CMS)
move card, fold back and forth along perforations.
CMS Contract # – Health plan-unique contract number
CMS information packet will follow.
Welcome to Healthassigned
Net. Yourby
benefit
7
Medicare Logo – Logo that identifies Part D prescription
Health Net Use Only
medication coverage (not applicable
members
Runto
Date
12/04/2007
52 - 2
To The Health Net
MedicareinAdvantage
Member:
This is
enrolled
Seniority
Plus Green)
N2
8
your current Health Net Identification card. Carry it with
ENG-MED-ADV-PARTD
you at all times, and present it to your Health Net
9
Name
– Name
of 17ED
the participating
9 Group/Physician
PPGParticipating
Name – Name
ofwhen
the
participating
physician group
Medicare Advantage
Physician
you
receive services.physician
See your
Evidence
of
Coverage
for is
a assigned
groupthe
(PPG)
to which
theCAM
member
(PPG)
to
which
member
CHIR is assigned
description of your benefits. When submitting inquiries
MHN INST M1
about your coverage, always include your Subscriber ID
SP+ CORE
of thePREVENTIVE
member’s(HN
number. 10 PCP Information – Name and address
DENTAL)
assigned primary care physician (PCP)
** No EOC
SAN FRANCISCO
M
2U4
14
Plan: 2T6 WI
your condition, y
your condition,
To
To remove
remove card,
card, fold
fold back
back and
and forth
forth along
along perforat
perforat
Identification (ID) Card
Health Net Components
1
RxProcessor
RxBIN #: 004
12RxPCN #: AD
RxGroup:
RX
13
To remove card, fold back and forth along pe
Material ID#
ID# H0562-07-0145
H0562-06-0322
CMS Approval
Approval (10/07)
(11/06)
To remove
back and forth along perforatio
You have selected the following medical group
for card,
your fold
care.
To remove
card, fold back and forth along perforat
All medical services, with the exception
of emergency,
urgently needed services, or out of the area renal dialysis for
ESRD members, as defined in your Evidence of Coverage,
Subscriber N
11 PPG/PCP
Telephone
must beContacts
provided or–arranged
by: numbers of the member’s
SUZANNE W
Group/Physician
assigned
PPG and Name:
PCP
BROWN AND TOLAND MEDICAL GROUP
Subscriber #
*338190120000040005*
emergency,
dialysis for
Coverage,
Subscriber #
For
For questions
questions or
or concerns,
concerns, call
call the
the Member
Member Services
Services Department
Department
Medical Claims:
Claims:
Medical
at
to
Health
Net
Comm
at 1-800-275-4737
1-800-275-4737 (TTY/TDD:
(TTY/TDD: 1-800-929-9955)
1-800-929-9955) 7:30
7:30 a.m.
a.m.
to
Welcome
to Health
Net.Net
Your
be
Health
Comm
For
questions
or
concerns,
call
the
Member
Services
Department
at
Medical
Claims:
12:00
p.m. and
andor1:00
1:00
p.m. to
tocall
5:00
p.m.,
Monday
through
Friday,
P.O. Box
Box 14702
14702
12:00
p.m.
p.m.
5:00
p.m.,
Monday
through
Friday,
For
questions
concerns,
the
Member
Services
Department
P.O.
Medical
Claims:
1-800-275-4737
(TTY/TDD:
1-800-929-9955)
8:00
a.m
to
8:00
Health
Net
Medica
except
holidays. (TTY/TDD: 1-800-929-9955) 7:30 a.m. to
Lexington, KY
KY 40
40
except
holidays.
Lexington,
at
1-800-275-4737
Health
Comm
p.m.,
7 days a week.
P.O.
BoxNet
14702
12:00
p.m. and
1:00 p.m.
to1-800-929-9224.
5:00 p.m., Monday through Friday,
P.O. Box 14702
For
Provider
inquiries,
call
Lexington,
KY
405
For
Provider
inquiries,
call
1-800-929-9224.
094893
For
Provider
inquiries, call 1-800-929-9224.
except
holidays.
KYAd
40
To The HealthLexington,
Net Medicare
00000F call 1-800-693-8951.
Pharmacists
Pharmacists
call
Pharmacists
call 1-888-865-6567.
1-800-693-8951.
your current Health Net Identific
ForKAREN
ProviderL.inquiries,
call
1-800-929-9224.
BRANSON
you at all times, and present it to
EUCLID
AVE
For1799
dental
benefits,
call Health
Health Net
Net Dental
Dental at
at 1-800-880-8113
1-800-880-8113
Medicare Advantage Participatin
For
dental
benefits,
call
Pharmacists
call 1-800-693-8951.
receive services.
See youra
APT 21
To contact
contact
aEvid
De
(TTY/TDD:1-800-880-3165)
To
De
(TTY/TDD:1-800-880-3165)
description of your
benefits. Wh
(TTY/TDD:
1-8
CA 94709
1263 Net
ForBERKELEY,
vision
benefits,
call Health
Health
Net Vision
at
1-866-392-6058
(TTY/TDD:
1-8
For
vision
call
at
dental benefits,
Dental
at 1-866-392-6058
1-800-880-8113
For
mental
health benefits,
call MHNVision
at 1-800-646-5610
To
contact
a Dec
about your coverage,
always
inc
(TTY/TDD:
1-866-308-5375)
(TTY/TDD:
1-866-308-5375)
To contact a1-80
De
(TTY/TDD:1-800-880-3165)
number.
(TTY/TDD:
(TTY/TDD:
1-800-327-0801)
For mental
mental
health
benefits
call,
MHN
at
1-800-646-5610
If
an
emergency
(TTY/TDD:
1-8
For
health
benefits
call,
MHN
at
1-800-646-5610
vision benefits, call Health Net Vision at 1-866-392-6058
If an emergency
(TTY/TDD: 1-800-327-0801)
1-800-327-0801)
care
(TTY/TDD:
1-866-308-5375)
emergency
care
Ifemergency
an emergency
your
condition,
Forchiropractic/acupuncture
mental
health benefits call
call,
MHN at 1-800-646-5610
If
an
emergency
For
1-800-678-9133
your
condition,
Material
ID#
H0562-06-0322
emergency
care
f
Material ID# H0562-06-0322
(TTY/TDD:
1-800-327-0801)
CMS
Approval1-877-710-2746)
(11/06)
(TTY/TDD:
emergency care
CMS
Approval
(11/06)
*338190120000040005*
ations.
your
ove
card,care.
fold back and forth along perforations.
PPG Eff. Date:
01-01-08
02-01-07
XXX
PPG #: 5044
15 copayment
PCP Copay: $10
Subscriber N
KAREN L BR
12 PPG Effective Date – Date the member was assigned
B BIRNBAUM
to GARY
the PPG
1580 Valencia St.
SAN
13 PPG
# –FRANCISCO
ID numberCA
for94110-4423
the PPG
PPG Eff. Date:
01-01-08
PPG #: 1316
PCP Copay: $10 copayment
RxProcessor
RxBIN #: 004
RxPCN #: AD
RxGroup: RX
14 PCP Copayment – Out-of-pocket expense the member is
Group Phone:
(TTY/TDD:
1-877-735-2929)
required
to pay for 1-415-972-6000
covered services
(copayments
vary
Physician Phone: 1-415-550-0811 (TTY/TDD: 1-877-735-2929)
by plan)
Plan: 2U4 W
15 Claims Information – Claims submission addresses
To remove card, fold back and forth along pe
16 Decision PowerSM – Contact information for health coaches
Welcome
to Health Net. Your be
17 Emergency Information – Instructions to member
on what
to do for an urgent or emergency health problem
028409
18 Important
Telephone Numbers – Health Net contactTo The Health Net Medicare Ad
00480B
telephone
numbers
SUZANNE
WALTERICH
64 BAYVIEW ST
19 Vendor
Contacts
– Contact
information
SAN
FRANCISCO,
CA 94124
2339
for
participating vendors administering certain
plan benefits
your current Health Net Identific
you at all times, and present it to
Medicare Advantage Participatin
receive services. See your Evid
description of your benefits. Wh
about your coverage, always inc
number.