Specialist: $** Copay

Rx(Generic/Brand): $*/$** Copay

Urgent Care: $5 Copay

ER: 25% Coinsurance

Ambetterhealth.com/copays Max Out-of-Pocket: $1,700

Plan: CMS Standard Silver RXBIN: 004336

Bronze Silver Gold Network Coverage Only RXPCN: ADV

RXGROUP: RX5453

REFERRAL FROM PCP NOT REQUIRED FOR SPECIALIST

BACK

Ambetter.mhsindiana.com

Member/Provider Services: 1-877-***-**** Medical Claims Address:

Y 1-800-***-****) MHS Indiana

24/7 Nurse Line: 1-877-***-**** Attn: CLAIMS

PO Box 5010

Numbers below for providers: Farmington MO

Pharmacy Help Desk: 1-866-***-**** 63640-5010

EDI Payor ID: 68069

‘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 responsibilty. For updated coverage

information, visit Ambettermhsindiana.com.

‘AMB22-IN-C-00013 ‘Ambetter from MHS is underwritten by Celtic Insurance Company.

© 2022 Celtic Insurance Company. All rights reserved.

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