Medical and Prescription Coverage Identification Card

Participant:  

RICHARD KEMP

I.D. No:  

USE PARTICIPANT SSN

Account Name:  

TEUTONIC TRANSPORTATION


Group/Account#:  

10556-00001

Effective Date:  

02/01/2024


Medical Coverage:  

FAMILY


VIP Tier PCP/SCP Copay:  

$0

Basic Tier PCP Copay:

$60

Basic Tier SCP Copay:

$120



VIP TIER DED/OOP

BASIC TIER DED/OOP


Individ

$0

100%

Individ

$6,000

100% TO $6,000*


Family

$0

100%

Family

$12,000

100% TO $12,000*



*Out of pocket includes deductible and copays


No PPO Network for Dialysis Treatment


Bin# 018893           PCN: MEDB           RX HELP DESK:  1-855-355-3015

Electronic Claims Payer ID: 74323


Send all claims to: MedBen P.O. Box 1099, Newark, OH 43506-1099



This plan does not utilize a PPO network and most services are paid at a % above


the Medicare fee schedule amount. For assistance with providers and balance


bill issues, please contact MedBen at 800-686-8425.



For pre-certification: Call 48 hours prior to an elective hospitalization


or surgery, or when pregnancy is verified. To Pre-certify contact Hines and


Associates at 888-461-0018.



Inter-Facility Air Ambulance Prior Authorization is recommended, call Sentinel


Air Medical Alliance at 877-542-8828.



For eligibility, benefits or claims information, call: 800-686-8425 / 740-522-8425


www.medben.com