Page 6 - Independence Blue Cross - PPO - Faegre Drinker

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PPO PROGRAM
PLAN FLEX PPO PCP $10 SPEC $20
ER $100 DED $200 PREV $0
VISION
Sample ID card Member: You need to get approval for services offered by providers outside our network by calling 1-800-ASK-BLUE (1-800-275-2583) Provider: For precertification call call 1-800-ASK-BLUE Non-network providers call 1-800-676-BLUE (1-800-676-2583) to verify eligibility and
coverage File all claims with local Blue Blue Cross®/Blue Shield® Plan Hospital: Please call 1-800-ASK-BLUE for admission notification within 48 hours or or next business after admission PPO PPO Program – PPO PPO SAMPLE MEMBER CUI123456789101
Rx Rx BIN Rx Rx PCN
Notes:
015814 06090000
• For For HCR products the the the PCN
will be be 06430000 and
the the the Pharmacy phone number is • For For Non-Flex plans the the the Plan name displays as PLAN PPO