Medicaid ID Card

Core

Health Plan Name:
Logo:
Sub Plan Logo:
Website URL:
Alt Website URL:
Member Portal URL:
FAP URL:
Benefits Page URL:
Rewards Page URL:
Address:
Rx BIN:
Rx PCN:
Rx Group:
PBM:

Member Services

Member Services Phone:
Member Services Phone/TDDTTY:
CentAccount Phone:
Relay Phone:
Relay Phone TDD/TTY:
Transportation Phone:
Service Coordinator:

Provider Services

Provider Services Phone:
Provider Services Fax:
Prior Auth Phone:
Eligibility Phone:
IVR Eligibility Phone:
Pharmacy Phone:
Vision Phone:
Dental Phone:

Behavioral Services

Behavioral Name:
Behavioral Phone:
Behavioral Website:
Behavioral Address:

Specialty Services

24/7 Nurse Line:
Nurse Line TDD/TTY:
Pharmacy Phone:
Dental Phone:
Dental Address:
Vision Phone:
Vision Address:

Co-Payment

Office Visit:
In-Patient:
Rx Brand:
Rx Generic:
Non-Emergency ER:
Provider Visit:
Preventative Visit:
Adult Dental Visit:
Inpatient Hospital Stay:

Prescriptions

$10.00 or less =
$10.01 to $25.00 =
$25.01 to $50.00 =
$50.01 or more =

Other

Medical Claims Who:
Medical Claims Address:
Grievance Phone:
Grievance Fax:
Medicaid Fraud Phone:
Payor ID:
Disclaimer:
ID Code:
Copyright:
Callout Text:
Provider Eligibility Check URL:
Imaging, X-Rays, Radiology:
DME, Home Health, Home Infusion:
Member Reimbursements: