Fidelis CareCommercial Clinical Policy

Sample Member ID Cards Form

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Sample Member ID Cards

Indications

(1) Is the request for Palm Ave., Suite 107 Fresno, CA 93711 Qualified Health Plans - Marketplace (Off Exchange) MEMBER ID #: [000000000-00] CIN #: [000000000] [MEMBER NAME] RXBIN: [004740] Pharmacy Benefits: Your prescriptions? 
(2) Is the request for [www.fideliscare.org] Healthier Life - HARP Managed Restricted Recipient Fidelis Care Member ID Cards MEMBER ID #: [000000000-00] CIN #: [000000000] [MEMBER NAME] RXBIN: [004740] Pharmacy Benefits: Your prescriptions? 

Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



Fidelis Care Member ID Cards PCP: [$10 copay after ded.] Specialist: [$25 coin. after ded.] Urgent Care: [20% coin. after ded.] ER: [$250 copay after ded.] MEMBER: [Jane Doe] Member ID: [XXXXXXXXX] Product: [Plan name] RXBIN: 003858 RXPCN: A4 RXGROUP: 2GKA Annual Deductible: [$10,000] Pharmacy: [$5/$25/$35] Inpatient: [$25,000] FidelisCare.org Member Services: 1-888-FIDELIS (1-888-343-3547) TTY: 711 Member Hours: Monday-Friday 8am to 6pm Medical Claims Address:
UB04 Fidelis Care Corporate Claims Dept. PO Box 806 Amherst, NY 14226-0806 FidelisCare.org Pharmacy Claims: Pharmacy Services 7625 N. Palm Ave., Suite 107 Fresno, CA 93711 Provider Services: 1-888-FIDELIS (1-888-343-3547) Provider Hours: Monday-Friday 8:30am to 5pm EDI Payor ID: 11315 Pharmacist Only: 1-833-750-4625 CMS 1500 Fidelis Care Corporate Claims Dept. PO Box 898 Amherst, NY 14226-0898 Essential Plan PCP: [$10 copay after ded.] Specialist: [$25 coin. after ded.] Urgent Care: [20% coin. after ded.] ER: [$250 copay after ded.] Pharmacy: [$25/$35/$35] MEMBER: [Jane Doe] Member ID: [XXXXXXXXX] Effective Date: [00/00/00] Plan: [Plan name] In Network Coverage Only RXBIN: 003858 RXPCN: A4 RXGROUP: 2GJA REFERRAL NOT REQUIRED FidelisCare.org/Ambetter Inpatient: [$7,965] Telemedicine: $0 Deductible: [$25,000] Max Out-of-Pocket: [$25,000] FULLY INSURED EXCHANGE Member/Provider Services: 1-888-343-3547 (TTY 711) Member Hours: Monday-Friday 8am to 6pm
Provider Hours: Monday-Friday 8:30am to 5pm Numbers below for providers: Pharmacist Only: 1-833-750-4625 EDI Payor ID: 11315 Davis Vision: 1-800-773-2847 DentaQuest: 1-888-308-2508 Medical Claims Address:
Fidelis Care Corporate Claims Dept. PO Box 724 Amherst, NY 14226-0724 FidelisCare.org AMB25-NY-C-00060 Pharmacy Claims: Pharmacy Services 7625 N. Palm Ave., Suite 107 Fresno, CA 93711 Qualified Health Plans - Marketplace (On Exchange) PCP: [$10 copay after ded.] Specialist: [$25 coin. after ded.] Urgent Care: [20% coin. after ded.] ER: [$250 copay after ded.] Pharmacy: [$25/$35/$35] MEMBER: [Jane Doe] Member ID: [XXXXXXXXX] Effective Date: [00/00/00] Plan: [Plan name] In Network Coverage Only RXBIN: 003858 RXPCN: A4 RXGROUP: 2GNA REFERRAL NOT REQUIRED FidelisCare.org/Ambetter Inpatient: [$7,965] Telemedicine: $0 Deductible: [$25,000] Max Out-of-Pocket: [$25,000] FULLY INSURED Member/Provider Services: 1-888-343-3547 (TTY 711) Member Hours: Monday-Friday 8am to 6pm
Provider Hours: Monday-Friday 8:30am to 5pm Numbers below for providers: Pharmacist Only: 1-833-750-4625 EDI Payor ID: 11315 Davis Vision: 1-800-773-2847 DentaQuest: 1-888-308-2508 Medical Claims Address:
Fidelis Care Corporate Claims Dept. PO Box 724 Amherst, NY 14226-0724 FidelisCare.org AMB25-NY-C-00060 Pharmacy Claims: Pharmacy Services 7625 N. Palm Ave., Suite 107 Fresno, CA 93711 Qualified Health Plans - Marketplace (Off Exchange)

   MEMBER ID #: [000000000-00]
                  CIN #: [000000000]

[MEMBER NAME] RXBIN: [004740]

Pharmacy Benefits: Your prescriptions are covered by Medicaid NYRx, the Medicaid pharmacy program. Locate a pharmacy that takes Medicaid NYRx at [https://member.emedny.org] PCP Name: [Physician Name / Go to members.fideliscare.org/PCP to Select PCP] PCP Phone: [1-XXX-XXX-XXXX] [RESTRICTED - CALL PLAN] Member Services Vision: [Davis Vision] Dental: [DentaQuest] [General NYRx Questions] [NYRx Prescription Specific Questions] Pharmacy Prior Auth (Providers Only) [1-888-343-3547] (TTY: 711) [1-800-601-3383] (TTY: 711) [1-800-516-9615] (TTY: 711) [1-800-541-2831] (TTY: [1-800-662-1220]) [1-518-486-3209] (TTY: [711]) [1-877-309-9493] (TTY: 711) Notice to Providers: This card does not guarantee a member's eligibility or payment for services rendered. Except for sudden emergency illness or injury, emergency room, inpatient or referral services must be arranged or authorized by Fidelis Care™. Fidelis Care™ must be notified within 24 hours of a member receiving emergency treatment. FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room (ER). [www.fideliscare.org] Healthier Life - HARP Managed Restricted Recipient

Fidelis Care Member ID Cards

   MEMBER ID #: [000000000-00]
                  CIN #: [000000000]

[MEMBER NAME] RXBIN: [004740]

Pharmacy Benefits: Your prescriptions are covered by Medicaid NYRx, the Medicaid pharmacy program. Locate a pharmacy that takes Medicaid NYRx at [https://member.emedny.org] PCP Name: [Physician Name / Go to members.fideliscare.org/PCP to Select PCP] PCP Phone: [1-XXX-XXX-XXXX] Member Services Vision: [Davis Vision] Dental: [DentaQuest] [General NYRx Questions] [NYRx Prescription Specific Questions] Pharmacy Prior Auth (Providers Only) [1-888-343-3547] (TTY: 711) [1-800-601-3383] (TTY: 711) [1-800-516-9615] (TTY: 711) [1-800-541-2831] (TTY: [1-800-662-1220]) [1-518-486-3209] (TTY: [711]) [1-877-309-9493] (TTY: 711) Notice to Providers: This card does not guarantee a member's eligibility or payment for services rendered. Except for sudden emergency illness or injury, emergency room, inpatient or referral services must be arranged or authorized by Fidelis Care™. Fidelis Care™ must be notified within 24 hours of a member receiving emergency treatment. FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room (ER). [www.fideliscare.org] HealthierLife - HARP Managed

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY]

   MEMBER ID #: [000000000-00]

[MEMBER NAME] Product: Fidelis Care at Home RXBIN: [003858] RXPCN: [MA] RXGRP: [2GGA] For diabetic testing and monitoring supplies only: Effective Date: [MM/DD/YYYY] Member Services Pharmacist Only [1-888-343-3547] (TTY: 711)
[1-833-750-4625] (TTY: 711) Pharmacist Only: For diabetes and monitoring supplies, call Express Scripts at the Pharmacist Only number above for any questions. Notice to Providers: This card does not guarantee a member's eligibility or payment for services rendered. Except for sudden emergency illness or injury, emergency room, inpatient or referral services must be arranged or authorized by Fidelis Care™. Fidelis Care™ must be notified within 24 hours of a member receiving emergency treatment. FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room (ER). [www.fideliscare.org] Member Services Vision: [Davis Vision] Dental: [DentaQuest] Pharmacist Only [1-888-343-3547] (TTY: 711)
[1-800-601-3383] (TTY: 711) [1-800-516-9615] (TTY: 711) [1-833-750-4625] (TTY: 711) Pharmacist Only: Call Express Scripts at the Pharmacist Only number above for any questions. Submit paper claims to the following address: [Pharmacy Services, 7625 N. Palm Avenue, Suite 107, Fresno, CA 93711] Notice to Providers: This card does not guarantee a member's eligibility or payment for services rendered. Except for sudden emergency illness or injury, emergency room, inpatient or referral services must be arranged or authorized by Fidelis Care™. Fidelis Care™ must be notified within 24 hours of a member receiving emergency treatment. FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room (ER). [www.fideliscare.org] MLTC

   MEMBER ID #: [000000000-00]

Dental Benefits FAMILY LINK ID #: [000000000000] [MEMBER NAME] RXBIN: [003858] RXPCN: [MA] RXGRP: [2GHA] Child Health Plus Member: [Member Full Name] [2026] [000000000-00] [H5599-XXX-000] [(80840) 9151014609] Card Issued: [MM/DD/YYYY] <PCP: [Physician Name]> <PCP Phone: [1-XXX-XXX-XXXX]> PCP Office Visit: [$X] Specialist Office Visit: [$X] Member portal MEMBER ID#: PLAN#: ISSUER#: [Plan Name] [(Plan Type)] < > <Part B Drugs Only> RXBIN: [XXXXX] RXPCN: [XXXXXXXXX] RXGRP: [XXXX] Member Services Nurse Advice Line Vision: [Versant] Dental: [DentaQuest] Provider Services / Pharmacy Prior Auth Pharmacist Only [1-800-247-1447] (TTY: 711) [1-800-581-9952] (TTY: 711) [1-XXX-XXX-XXXX] (TTY: 711) [1-833-493-0652] (TTY: 711) [1-888-343-3547] (TTY: 711) [1-833-750-4593] (TTY: 711) [go.wellcare.com/FidelisNY] Medical Claims: [Wellcare By Fidelis Care P.O. Box 170, Amherst, NY 14226-0170] Payor ID: [11315] <Part D Claims: [Wellcare By Fidelis Care Attn: Medicare Part D Member Reimbursement Dept. P.O. Box 31577 Tampa, FL 33631-3577]> FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room Medicare - Wellcare By Fidelis Care

Fidelis Care Member ID Cards Member: [Member Full Name] [2026] [000000000-00] [0123456789012] [H5599-XXX-000] [(80840) 9151014609] Card Issued: [MM/DD/YYYY] <Member Type: Integrated Benefit Dual> <PCP: [Physician Name]> <PCP Phone: [1-XXX-XXX-XXXX]> PCP Office Visit: [$X] Specialist Office Visit: [$X] Member portal MEMBER ID#: CIN#: PLAN#: ISSUER#: [Plan Name] [(Plan Type)] RXBIN: [610014] RXPCN: [MEDDPRIME] RXGRP: [2FFA] Member Services Nurse Advice Line <Vision: [Provider] Dental: [DentaQuest] Provider Services / Pharmacy Prior Auth Pharmacist Only [1-800-247-1447] (TTY: 711) [1-800-581-9952] (TTY: 711) [1-XXX-XXX-XXXX] (TTY: 711)> [1-XXX-XXX-XXXX] (TTY: 711) [1-888-343-3547] (TTY: 711) [1-833-750-4593] (TTY: 711) [go.wellcare.com/FidelisNY] Medical Claims: [Wellcare By Fidelis Care P.O. Box 170, Amherst, NY 14226-0170] Payor ID: [11315] Part D Claims: [Wellcare By Fidelis Care Attn: Medicare Part D Member Reimbursement Dept. P.O. Box 31577 Tampa, FL 33631-3577] FOR EMERGENCIES: Dial 911 or go to the nearest Emergency Room Medicare - Wellcare By Fidelis Care Dual

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