FRONT

@ ambetter.

of Tennessee

Subscriber: Dolse Murphy Policy U70842439

Member: Dolse Murphy Member ID —U7084243901

Effective 09/01/2023

PCP: SO

Specialist: $10

Rx(Generic/BGogays0/$15

Urgent Care: {fapay

ER: 25%

Ambetterhealth.com/copays Max@hitenfance $1,700

Pocket:

Plan: CMS Standard Silver RXBIN: 004336

Bronze Silver Gold Network Coverage Only RXPCN: ADV

RXGROUP: RX5475

REFERRAL FROM PCP NOT REQUIRED FOR SPECIALIST

BACK

Ambetteroffennessee.com

Member/Provider 1-833-709- Medical Claims Address:

Geekiges:1) 4735 Ambetter of Tennessee

24/7 Nurse 1-833-709- Attn: CLAIMS

Hisipers below for >> eo Box soit

. Farmington, MO

Phoniderey Help 1-855-266- 63640-5010

BpsRayor 68069 3480

ID:

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 AmbetterofTennessee.com.

Ambetter of Tennessee is underwritten by Celtic Insurance Company.

AMB22-TN-C-00013 © 2022 Celtic Insurance Company. All rights reserved.