Attached issued card(s). are

RUN_DATE
DATA_SEQ_NO
CLIENT_NUMBER
UHG_TYPE
DOC_ID
DOC_SEQ_ID
NAME
MAILSET_NUMBER
DREW
9452811/000001-00
9452811/000001-01
9452811/000001-02
DIG2CARD
20110607
0000001
0000001
003113
0000001
10:52:45
,JOANNE
003113
By accepting this card and any benefits to which this card entitles the holder,
the holder acknowledges that the policy/agreement pursuant to which this
card is issued constitutes a contract solely between the group and Blue Cross
and Blue Shield of Texas (BCBSTX), or HMO Blue 7 Texas, and that BCBSTX
and HMO Blue Texas are independent corporations operating under a license
with the Blue Cross and Blue Shield Association which permits BCBSTX and
HMO Blue Texas to use the Blue Cross Blue Shield names and service marks
in the State of Texas.
001
BlueCross BlueShield of Texas
P.O. Box 655730
Dallas, TX 75265-5730
9452811
Attached are your new ID cards. Please discard any previously
issued card(s). Always present your most current ID card to the
hospital or provider when you or your covered dependents seek
health care.
>000001
TEST
www.bcbstx.com
Subscriber Name:
ABC SAMPLE
Identification Number:
123456789
Group Number:
Coverage Date:
Network Number:
123456
01/01/10
PTXOA
FAMILY
Office Visit
Emergency Room
Urgent Care
RX Generic Copay
RX Brand Copay
RxBIN: 011552
RxPCN: BCTX
$25
$50
$35
$10
$30/$50
Network coverage is available through
participating network providers. Non-network
services will be covered at a lower level.
Some services must be pre-authorized,
including Mental Health (MH) and Chemical
Dependency (CD). Refer to your benefits booklet
for claims filing address and additional
information.
Providers: File claims with your local BCBS
plan.
Customer Service
Preauth-Medical
Preauth-MH/CD
Blue Card Access
Provider Service
1-800-521-2227
1-800-441-9188
1-800-528-7264
1-800-810-2583
1-800-451-0287
BlueCross BlueShield of Texas, an independent
licensee of the BlueCross BlueShield
Association, provides claims processing only
and assumes no financial risk for claims.
Pharmacy Benefits Manager
0311394528110000000000100000011530 117
www.bcbstx.com
Subscriber Name:
ABC SAMPLE
Identification Number:
123456789
Group Number:
Coverage Date:
Network Number:
123456
01/01/10
PTXOA
FAMILY
Office Visit
Emergency Room
Urgent Care
RX Generic Copay
RX Brand Copay
RxBIN: 011552
RxPCN: BCTX
$25
$50
$35
$10
$30/$50
Network coverage is available through
participating network providers. Non-network
services will be covered at a lower level.
Some services must be pre-authorized,
including Mental Health (MH) and Chemical
Dependency (CD). Refer to your benefits booklet
for claims filing address and additional
information.
Providers: File claims with your local BCBS
plan.
Customer Service
Preauth-Medical
Preauth-MH/CD
Blue Card Access
Provider Service
1-800-521-2227
1-800-441-9188
1-800-528-7264
1-800-810-2583
1-800-451-0287
BlueCross BlueShield of Texas, an independent
licensee of the BlueCross BlueShield
Association, provides claims processing only
and assumes no financial risk for claims.
Pharmacy Benefits Manager
Shipper ID: 00000000
Shipping Method: DIRECT
CARRIER: USPS
Address:
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Cycle Date: 20110602
PDF Date: Tue Jun 07, 2011 @ 10:52:45
MaxMover: N
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