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Sample Bin Card Format

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					                                       Sample Identification Cards

                BlueCross BlueShield                                      BlueCross BlueShield
                                                                          BluePlus


RxBIN 610455     RxPCN PGIGN                                    RxBIN 610455     RxPCN PGIGN
GRP         TQ570-A0                                            GRP         TO302-ZB
ISSUER      NOT ASSIGNED                                        ISSUER       NOT ASSIGNED
ID         XZA XZ9999999                                        ID          XZB XZ9999999
NAME        00 ELIZABETH M SAMPLENAME                           NAME        00 ELIZABETH M SAMPLENAME
CARE TYPE AWARE GOLD                                            CARE TYPE TRIPLE GOLD
SVC TYPE RX Covrg      Office Copay Spclty Netwk                SVC TYPE RX Covrg     Office Copay Spclty Netwk
           GOLD NET      15.00         YES                                 GOLDNET      15.00           YES
                                                                PCP MEMBER’S PRIMARY CARE CLINIC

     Blue Cross and Blue Shield of Minnesota                                        Blue Plus
•    Fee-for-service plan                                       •   Managed care plan
•    Members can see any participating provider                 •   Lists primary care clinic
                                                                •   Member must coordinate care through their
                                                                    primary care clinic


               BlueCross BlueShield                                       BlueCross BlueShield        BASIC
                                                                                                 MEDICARE SELECT
                                                                                                    SENIOR GOLD

RxBIN 610455    RxPCN PGIGN                                     RxBIN 610455    RxPCN PGIGN
GRP        Y0831-AC                                             GRP         Y0839-SG
ISSUER      NOT ASSIGNED                                        ISSUER      NOT ASSIGNED
ID         XZA XZ9999999                                        ID         XZM XZ9999999
NAME       00 JOHN A SAMPLENAME                                 NAME       00 JOHN A SAMPLENAME
CARE TYPE COMPREHENSIVE MAJOR MED                               CARE TYPE MEDICARE SUPPLEMENT
SVC TYPE RX Covrg     Office Copay Spclty Netwk                 SVC TYPE RX Covrg
           GOLD NET     NONE          YES                                  GOLD NET

                     Individual                                             Medicare Supplement
•    Group number starts with “Y0”                              •   ID number has XZM alpha prefix
•    They obtain coverage directly with Blue Cross,             •   Group number starts with “Y0”
     not through an employer                                    •   Individual account, not through employer

              BlueCross BlueShield
               Federal Employee Program
               fepblue.org

Government-Wide Service Benefit Plan
JOHN A SAMPLENAME
contract holder name
R99999999
identification number

enrollment code                effective date of coverage

                             RX Bin # 61041
                             RX Group # 6500650
            Federal Employee Program                             Blue Advantage (PMAP, PGAMC, MSC/MSC+)
•    ID# begins with R then 8 digits                            • ID# starts with 80
•    Three plan options:                                        • Group number begins with the letters PP
     Standard Option:          group number 0S500-03            • Lists PCC (eligibility may change monthly,
     Basic Option:             group number 0S500-02              verify on state’s EVS at 1-800-657-3613)
     Basic Consumer Option: group number 0S500-04
     (sub-option of Basic Option. A High Deductible
     Health Plan/HDHP)




X14694R12 (11/08)                                           1
                                            Sample Identification Cards
                                             MI MINNESOTA ADVANTAGE
                                             HEHEALTH PLAN                          BlueCross BlueShield
     Blue Cross Blue Shield
         of Minnesota
                                                                         00 JOHN A SAMPLENAME
     PROVIDER NAME PRINTS HERE XXXX
     00 JOHN A SAMPLENAME
                                                                         GROUP NUMBER
     GROUP NUMBER                     IDENTIFICATION NUMBER              XX199-11              IDENTIFICATION NUMBER
                                            XZA XZ9999999                                          YQA 9999999999
     0S228-ZX

     RxBIN       RxPCN        RX COVRG       OFFICE COPAY                                                  IN NETWORK
     610455      PGIGN        GOLD SELECT         15.00                           ER COPAY                  OFFICE COPAY
                                                                                  75.00                    10.00
     CONTRACT YEAR 2008
              Minnesota Advantage Health Plan                                                 BlueCard
     •    Managed care product for employees of the                      •   Identify by the three-digit alpha prefix in
          State of Minnesota                                                 front of ID number and an empty suitcase.
     •    Group number: 0S228Z_                                              Some cards have “PPO in a suitcase” logo
     •    Lists primary care clinic                                      •   Member covered through another Blue Plan
     •    Member benefits are determined by the PCC the                  •   Call the BlueCard eligibility line to verify
          member selects                                                     eligibility and get benefits: 1-800-676-2583




                   Simply Blue                                           Example of new Fully insured ID card that will
     •    Individual healthcare product                                  be issued in November 2008 for new members
     •    No dependent coverage-single policies only                     and reissued cards for Blue Cross and Blue Plus,
     •    Must be resident of Minnesota or have VISA                     including government programs and Medicare
     •    No maternity coverage (prenatal is covered)                    and FirstPlan. By January 1, 2011, all members
                                                                         will have new card format.
  Fully insured groups            • must follow state and federal mandates
                                  • members receive standard ID cards

  Self-insured groups             • not required to follow state mandates but may select them
                                  • must follow federal mandates
                                  • ID cards are not standard, may include company logo

  Managed Care                    • (Blue Plus) member selects a primary care clinic
                                  • may need referral to specialists for highest level of benefits

  Fee-for-service                 • (Blue Cross and Blue Shield) no primary care clinic designation
                                  • member utilizes network of physicians and specialists for highest benefits

Information on this handout is general information. Provider and/or member contracts determine benefits.

    X14694R12 (11/08)                                         2

				
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Description: Sample Bin Card Format document sample