Member Identification Card Quick Reference Guide

1 Member Identification card Quick Reference Guide Member Identification cards contain important membership and coverage information that help you correctly route your claims. Be sure to verify eligibility using carefirst Direct or carefirst on Call prior to rendering care. The front of the Member ID card contains [Network information about the Member , the primary care 1 Logo] 4. provider (PCP), copayments/coinsurance and Member Name [Product Name]. some Member benefits FIRST NAME LAST NAME. Member ID 5 [GROUP NAME]. PCP Name ### ###### [LAST NAME, FIRST NAME]. 2 Group #### Coverage IND. 1 carefirst logo 6 P$0 S$30 CC$0 UC$50 ER30%. RX PD PV. 2 M. ember ID and Group number Medical In-Network Out-of-Network 3 R. x deductible and out-of-pocket max Eff Date 01/01/2021. BC/BS Plan 190/960. 7 IND Deductible IND Out-of-Pocket $1000.

2 $5000. $4000. $8000. Rx Deductible IND $100. 3 Rx Out-of-Pocket IND $500 8. 4 Plan network 5 Plan name, PCP name (if applicable) For eligibility or benefits: 410-872-9500. Benefit copay information To find a provider: 6 Pre-Certification: ###-###-####. [Legal disclosures and claims filing instructions.]. Vision Service Plan (VSP)*: ###-###-####. P PCP CC Convenience Care *Not a Blue Cross Blue Shield service. S Specialist UC Urgent Care Providers must submit all claims to local Blue Cross and Blue Shield Plan. OV Office Visit ER Emergency Room For services refer to the phone number at the top of this card . 7 Deductible and out-of-pocket max [Address]. [City, State, ZIP]. carefirst BlueCross BlueShield is the shared business name of 8 BlueCard program identifier carefirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.

3 , which are independent licensees of the Blue Cross and Blue Shield Association. BLUE CROSS , BLUE SHIELD . and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Back of card CODE (X/XX). The back of the Member ID card includes contact information for members, as well as instructions and an address for filing claims and sending correspondence. Member ID cards may include one of several logos identifying the type of coverage the Member has and/or indicating the provider's reimbursement level. Product information Products Prefixes Logo Health Maintenance BlueChoice HMO XIK, XIR, XIB, QXG, Organization (HMO) BlueChoice HMO Open Access QXA, XIE, JHZ, XWZ, XIG, QXK, XIC, XIH. Point of Service (POS) BlueChoice Opt Out BlueChoice Opt Out Plus Open Access*.

4 BlueChoice Opt Out Open Access*. BlueChoice Advantage BlueChoice Plus * Open Access = no referral needed if the provider is in the BlueChoice Network Preferred Provider BluePreferred PPO XIL, XWV, JHJ, XII, JHI, Organization (PPO) XIQ, QXM, XIY, XIU. Federal Employee FEP Basic Option R. Program (FEP) FEP Standard Option FEP Blue Focus HealthyBlue HealthyBlue Advantage JHG, QXF, JHA, JHC, HealthyBlue Open Access QXB, QXE, XIF, JHD, HealthyBlue Plus Open Access QXD, JHH, QXI, QXL, Focused on you. QXU, QXR, QXS, HealthyBlue PPO. QXT, QXC, QXH Focused on you. HealthyBlue HMO. Focused on you. Maryland Point of Maryland Point of Service Varies Service (MPOS). National Account All products, except FEP Unique prefix. Service Company carefirst IDs have (NASCO) plan codes 080/580. and 190/690. MedPlus Medigap Plan A, B, F, G, L, M, N XWC.

5 Medigap Plan High Ded F. Medicare Advantage carefirst BlueCross BlueShield Prefix MAC. Advantage Core carefirst IDs have carefirst BlueCross BlueShield plan code 193. Advantage enhanced Out-of-area coverage (BlueCard). Logo description What it looks like What it means (type of out of area coverage). A blank (empty) Member has out of area coverage for urgent or suitcase icon emergency care. A suitcase icon with Member has PPO or EPO benefits available for PPO inside medical services received inside or outside of the A suitcase icon with Member has out-of-area coverage for urgent or BlueHPN inside emergency care. carefirst BlueCross BlueShield is the shared business name of carefirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. carefirst BlueCross BlueShield Medicare Advantage is the shared business name of carefirst Advantage, Inc.

6 , carefirst Advantage PPO, Inc. and carefirst Advantage DSNP, Inc. carefirst BlueCross BlueShield Community Health Plan Maryland is the business name of carefirst Community Partners, Inc. carefirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. In the District of Columbia and Maryland, carefirst MedPlus is the business name of First Care, Inc. In Virginia, carefirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). carefirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., carefirst Advantage, Inc., carefirst Advantage DSNP, Inc., carefirst Community Partners, Inc., Trusted Health Plan (District of Columbia), Inc., carefirst BlueChoice, Inc., First Care, Inc.

7 , and The Dental Network, Inc. are independent licensees of the Blue Cross and Blue Shield Association. BLUE CROSS , BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. CST0491-1E (11/21).