Page 6 - Archdiocese-of-Philadelphia-Open-Enrollment-Brochure
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Sample ID ca
Memb
for care referral Southea 1-800-A hours o 1-800-6 eligibili local Bl Please c notifica after ad
SAMPLE MEMBER YXH123456789101
DR BEN FRANKLIN MD 215-555-1212
LAB Q
Rx BIN Rx PCN
015814 06090000
PLAN FLEX HMO PCP $5
SPEC $10
ER $25
DED $1000 PREV $0
VISION
Notes:
• For HCR products, the PCN will be 06430000 and the Pharm • For Non-Flex plans, the Plan name displays as PLAN HMO
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