PRODUCTION VIEW
PCP:
CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Lung Care
CMS H1423-PBP: 001-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
Plus (HMO C-SNP)
RxID:
$0$35
$120$0
X634494900001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/01/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-855-658-92491-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2931296
11/01/202011/05/2020
Card Front Card Back
PRODUCTION VIEW
PCP: PCP Phone: (CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Diabetes
CMS H1423-PBP: 002-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
Care Plus (HMO C-SNP)
RxID:
$0$35
$120$0
X634924500001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/02/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-589-31481-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2932864
11/02/2020
Card Front Card Back
PRODUCTION VIEW
PCP: PCP Phone: CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Heart
CMS H1423-PBP: 003-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
Care Plus (HMO C-SNP)
RxID:
$0$35
$120$0
X634494900034
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/01/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-589-31481-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2931296
11/01/202011/05/2020
Card Front Card Back
PRODUCTION VIEW
PCP:
CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Classic Plus
CMS H1423-PBP: 004-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
(HMO)
RxID:
$0$35
$120$0
X634494900041
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/01/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-291-37581-800-589-31481-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2931296
11/01/202011/05/2020
Card Front Card Back
PRODUCTION VIEW
PCP: PCP Phone: (CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Smart Value
CMS H1423-PBP: 005-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
Plus (HMO)
RxID:
$10$40
$120$0
X634924500010
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/02/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-589-31481-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date
2932864
11/02/2020
Card Front Card Back
PCS PREVIEW
Intentionally Left Blank
PCP: PCP Phone: CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage CareMore Care
CMS H1423-PBP: 008-000
To You Plus (HMO I-SNP)
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
RxID:
$0$0
$120$0
X146864942400001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 11/07/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-498-1582Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-589-31481-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
X146864942400001
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date
Single Card PackageCard Front Card Back
PCS PREVIEW
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PCP: T. GUPCP Phone: (
Rx BIN: 020115Rx PCN: IS
Rx GROUP: WM2AIssuer ID: 80840
Member ID:
Amerivantage Heart Care
CMS H2593-PBP: 013-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
(HMO C-SNP)
Rx ID:
$0$35$90
$0
Enhanced Dental and Vision Package
X36436864900001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 09/23/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-337-1266Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-446-00371-855-658-92491-855-741-4985
Providers:Dental:Vision:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Transportation: 1-844-923-0755
X36436864900001
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date609003
Single Card PackageCard Front Card Back
PRODUCTION VIEW
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PCP:
CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID
Amerivantage Classic (HMO)
CMS H2593-PBP: 001-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
RxID:
$0$35$90
$0
X634145400003
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 10/30/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-337-1266Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-855-658-92491-855-741-4985
Providers:Dental:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
X634145400003
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2926745
10/30/202011/03/2020
Single Card PackageCard Front Card Back
PRODUCTION VIEW
PCP: PCP Phone: (CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Lung Care
CMS H2593-PBP: 005-000
(HMO C-SNP)
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
RxID:
$0$35$90
$0X634494000001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 10/31/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-337-1266Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-855-658-92491-855-741-49851-844-923-0755
Providers:Dental:24/7 NurseLine:SilverSneakers:Transportation:
of treatment.
amerigroup.com/medicare
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2929820
10/31/202011/05/2020
Card Front Card Back
PRODUCTION VIEW
Intentionally Left Blank
PCP: -
CareMore Health - Arizona
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Diabetes
CMS H2593-PBP: 006-000
Care (HMO C-SNP)
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
RxID:
$0$35$90
$0
X634481800001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 10/31/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-833-337-1266711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc:
1-888-816-2790
Help for Pharmacists: 1-833-377-42661-888-291-13581-888-700-09921-855-658-92491-855-741-49851-844-923-0755
Providers:Dental:24/7 NurseLine:SilverSneakers:Transportation:
of treatment.
amerigroup.com/medicare
X634481800001
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date2929820
10/31/202011/03/2020
Single Card PackageCard Front Card Back
PRODUCTION VIEW
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PCP: PCP Phone:
RxBIN: 020115RxPCN: ISRxGRP: WM2A
Issuer ID: 80840
Member ID:
Amerivantage Smart Value
CMS H2593-PBP: 018-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
(HMO)
RxID:
$10$40
$120$0
Enhanced Dental and Vision Package
X634481800038
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 10/31/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-337-1266Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-446-00371-855-658-92491-855-741-4985
Providers:Dental:Vision:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
Transportation: 1-844-923-0755
X634481800038
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date
2929820
10/31/202011/03/2020
Single Card PackageCard Front Card Back
PCS PREVIEW
Intentionally Left Blank
PCP: M. MPCP Phone: (408)
Rx BIN: 020115Rx PCN: IS
Rx GROUP: WM2AIssuer ID: 80840
Member ID:
Amerivantage CareMore Care
CMS H2593-PBP: 019-000
Office Visit Copay:Specialist Visit Copay:Emergency Room Copay:Preventive Copay:livehealthonline.com
To You (HMO I-SNP)
Rx ID:
$0$0
$120$0
Enhanced Dental and Vision Package
X7030265000001
Members: Present this ID card to your
Customer Service:
or supplies. See your Evidence of Coverage forcovered services.Providers and Hospitals: Prior authorizationis required for all non emergency admissionsand certain services. For emergency
Claims: Amerigroup, P.O. Box 366Artesia, CA 90702-0366
Pharmacy Claims: P.O. Box 52077Phoenix, AZ 85072-2077
Use of this card by any person other than the member is fraud 10/05/2020
admissions, please call within 24 hours
EDI Information : Payer ID - CARMO
1-888-816-2790711
healthcare provider before you receive services
TTY:Pharmacy Member Srvc: 1-833-337-1266Help for Pharmacists: 1-833-377-4266
1-888-291-13581-888-700-09921-800-446-00371-800-589-31481-855-741-4985
Providers:Dental:Vision:24/7 NurseLine:SilverSneakers:
of treatment.
amerigroup.com/medicare
X7030265000001
Mail to AddressMember NameMember IDJob ID
Processed DateExpected Mail DateActual Mail Date
10/05/2020
Single Card PackageCard Front Card Back