Front

IN NETWORK
COVERAGE ONLY

Subscriber: Garret Harris Effective Date of Coverage:

Member: Garret Harris 06/01/2018
Policy #: 92129697 RXBIN: 004336
Member ID #: U9212969701 RXPCN: ADV
Plan: Ambetter Balanced Care 1 (2018) + Vision RXGROUP: RX5446

Copays:  
PCP: n/a Int. Coinsurance: 20.00%
Specialist: $10.00 Int. Deductible: $0
Urgent Care: $10.00 Rx (Generic/Brand): n/a / $25.00
ER: n/a

Back
Ambetter.pshpgeorgia.com

Member/Provider Services: Medical Claims:

1-877-687-1180 Peach State Health Plan
TDD/TTY: 1-877-941-9231 Attn: CLAIMS
24/7 Nurse Line:1-877-687-1180 PO Box 5010
Numbers below for providers: Farmington, MO
Pharmacy Help Desk:1-800-261-3181 63640-5010
EDI Payor ID: 68069
EDI Help Desk: Ambetter.pshpgeorgia.com

Additional information can be found in your Evidence of Coverage. If you have an Emergency, call 911 or go to the nearest
Emergency Room(ER). Emergency services given by a provider not in the plan's network will be covered without prior
authorization. Receiving non-emergent care through the ER or with a non-participating provider may result in a change to
member responsibility. For updated coverage information, visit Ambetter.pshpgeorgia.com.

© 2016 Ambetter of Peach State Inc. All rights reserved.

If you have selected a new coverage plan, please allow 24/48 hours for your ID card to reflect the changes.