www.lacare.org

THIS IS YOUR ID CARDÉSTA ES SU TARJETA DE IDENTIFICACIÓN

LA0715 02/12FRONT

Thank you for choosing L.A. Care Health Plan!Attached below is your new member ID card. Fold the card and keep it with you. Show this card tothe health care provider when you get services. If you need an interpreter, call 1-888-839-9909.

¡Gracias por escoger L.A. Care Health Plan!Aquí se adjunta su nueva tarjeta de identificación de miembro. Doble la tarjeta y téngala a la mano.Enseñe la tarjeta a su proveedor de atención médica cuando necesite obtener servicio. Si necesita losservicios de un intérprete, llame al 1-888-839-9909.

1-888-839-9909

1-888-839-9909

PASC-SEIU Homecare Workers Health Care Plan

Office Visit: $5Specialist: $2ER Visit: $35 (Waived if Admitted)Rx: $5

PRIMARY HOSPITAL:

PPG:

PCP:

NAME: MEMBER ID:

PCN: 56805

Rx BIN: 003585

Urgent Care: $5

Drug carve-out list for L.A. Care Medi-Cal members only: The drugs listed should be submitted to Medi-Cal Fee-For-Service (FFS) and written on “Tamper Resistant Prescription Pads.” Healthy Kids, Healthy Families Program, IHSS and Medicare

members refer to www.lacare.org to view formulary coverage.

PBM-MedImpact: 800-788-2949Member ID: CIN#Eligibility: 866-522-2736Prior Auth: 888-648-6765Prior Auth Fax: 858-790-7100Telephonic Interpreter ServicePharmacist: 888-942-7670Doctor: 888-930-3031

PBM-MedImpact: 800-788-2949Member ID: CIN#Rx BIN: 003585PCN: 56805Eligibility: 866-522-2736Prior Auth: 888-648-6765Telephonic Interpreter ServicePharmacist: 888-942-7670Doctor: 888-930-3031

Medicare Advantage HMO SNP PASC SEIU Homecare Workers Health Care Plan for In-Home Supportive Services (IHSS) Workers

PBM-Express Scripts: 800-227-3032Member ID: CIN#Eligibility: 800-407-4627Prior Auth: 888-831-2242Prior Auth Fax: 888-831-2243Interpreter Service: 888-285-7801

ANTHEM BLUE CROSSPBM-MedImpact: 800-788-2949Member ID: CIN #Eligibility: 800-605-2556Prior Auth: 877-792-2731Prior Auth Fax: 323-889-6254Interpreter Service: 800-605-2556

CARE 1ST HEALTH PLANPBM-MedImpact: 800-788-2949Member ID: CIN#Eligibility: 866-522-2736Prior Auth: 800-788-2949Prior Auth Fax: 858-790-7100Telephonic Interpreter ServicePharmacist: 888-942-7670Doctor: 888-930-3031

L.A. CARE HEALTH PLANKaiser members must have their prescriptions filled at a Kaiser pharmacy. For information call Kaiser Member Services at 800-464-4000. Kaiser members may fill carve out medications at any pharmacy that bills Medi-Cal FFS.

KAISER PERMANENTE

Medi-Cal

Please note a Medicare card that includes Member ID Information indicates a member enrolled in both Medicare Advantage and Medi-Cal Programs.

Please note beginning October 1st 2012, CHP will NO LONGER participate in the Healthy Families program.

<Pl

aceh

olde

r Add

ress

Blo

ck>

LA0645 12/11

Attached is your new

mem

ber ID card. D

etach the card and keep it w

ith you. Show this card to the health care

provider when you get services. If you need an interpreter,

call 1-888-522-1298. TT

Y/T

DD

users should call 1-866-522-2731. L

.A. C

are Health P

lan representatives are available 24 hours a day, 7 days a w

eek.

L.A. C

are Health Plan is a C

oordinated Care plan w

ith a Medicare A

dvantage contract and a contract w

ith the California M

edicaid program.

¡Gracias por elegir L.A

. Care Health Plan!

Aquí se adjunta su nueva tarjeta de identificación de m

iembro. Separe la

tarjeta y téngala a mano. M

uestre esta tarjeta a su proveedor de atención m

édica cuando reciba servicios. Si necesita los servicios de un intérprete, llam

e al 1-888-522-1298. Los usuarios de T

TY

/TD

D deben llam

ar al 1-866-522-2731. L

.A. C

are Health P

lan cuenta con representantes que están disponibles las 24 horas del día, los 7 días de la sem

ana.

L.A. C

are Health Plan es un plan de salud con servicios de atención m

édica coordinada que tiene contratos con M

edicare Advantage y el program

a C

alifornia Medicaid. Thank you for choosing L.A

. Care Health Plan!

ww

w.lacare.o

rg

Medicare Advantage (HMO SNP)

Office Visit: $0Specialist: $0ER Visit: $0Dental: $0Vision: $0

PCP:

NAME:

MA-SNP ID:

ISSUER: 80840

RxBIN: 015574RxPCN: ASPROD1RxGroup: LAC05RxID:

<placeholder name> <placeholder phone>

<placeholder name>

<placeholder ID>

ISSUER: 80840

RxBIN: 015574RxPCN: ASPROD1RxGroup: LAC05RxID: <placeholder ID>

H2643_2020_2012 C

MS

Approved 10172011

THIS IS YOUR ID CARD • ÉSTA ES SU TARJETA DE IDENTIFICACIÓN

CMS-H2643 001

LA03

50 0

5/12

Immediate Access to Accurate Member Eligibility Information 24 Hours a Day! 1-866-LA-CARE6 or 1-866-522-2736

PBM-MedImpact: 800-788-2949Member ID: CIN#Eligibility: 866-522-2736Prior Auth: 800-788-2949Prior Auth Fax: 858-790-7100Telephonic Interpreter ServicePharmacist: 888-942-7670Doctor: 888-930-3031

Healthy Kids & Healthy Families

Drugs for management of HIV/AIDS complexAbacavir/Lamivudine EpzicomAbacavir Sulfate ZiagenAmprenavir AgeneraseAtazanavir Sulfate ReyatazDarunavir Ethanolate PrezistaDelavirdine Mesylate RescriptorEfavirenz SustivaEfavirenz/Emtricitabine/

Tenofovir Disoproxil Fumarate AtriplaEmtricitabine EmtrivaEnfuvirtide FuzeonEtravirine IntelenceFosamprenavir Calcium LexivaIndinavir Sulfate CrixivanLamivudine EpivirLopinavir/Ritonavir KaletraMaraviroc SelzentryNelfinavir Mesylate ViraceptNevirapine ViramuneRaltegravir Potassium IsentressRitonavir Novir

Rilpivirine HCI EdurantSaquinavir FortovaseSaquinavir Mesylate InviraseStavudine ZeritTenofovir Disoproxil- Emtricitabine TruvadaTenofovir Disoproxil Fumarate VireadTipranavir AptivusZidovudine/Lamivudine CombivirZidovudine/Lamivudine/Abacavir Sulfate Trizivir

Drugs for management of Psychosis/ Severe Emotional Disorder (SED)Amantadine HCl SymmetrelAripiprazole AbilifyAsenapine SaphrisBenztropine Mesylate CogentinBiperiden HCl AkinetonBiperiden Lactate AkinetonChlorpromazine HCl ThorazineChlorprothixene TaractanClozapine ClozarilFluphenazine Decanoate ProlixinFluphenazine Enanthate ProlixinFluphenazine HCl Prolixin

Haloperidol HaldolHaloperidol Decanoate HaldolHaloperidol Lactate HaldolIloperidone Fanapt Isocarboxazid MarplanLithium Carbonate EskalithLithium Citrate LithobidLoxapine HCl LoxitaneLoxapine Succinate LoxitaneLurasidone HCL LatudaMesoridazine Mesylate Serentil InjMolindone HCl MobanOlanzapine ZyprexaOlanzapine Fluoxetine HCl SymbyaxOlanzapine Pamoate Monohydrate (Zyprexa Relprevv) Paliperidone InvegaPaliperidone Palmitate Invega SustennaPerphenazine TrilafonPhenelzine Sulfate NardilPimozide OrapProclyclidine HCl KemadrinPromazine HCl SparineQuetiapine Seroquel

Risperidone RisperdalRisperidone Microspheres Risperdal-MSelegiline EmsamThioridazine HCl MellarilThiothixene NavaneThiothixene HCl NavaneTranylcypromine Sulfate ParnateTrifluoperazine HCl StelazineTriflupromazine HCl VesprinTrihexyphenidyl ArtaneZiprasidone GeodonZiprasidone Mesylate Geodon Inj

Alcohol, Heroin Detoxification and Dependency treatment drugs

Acamprosate Calcium CampralBuprenorphine HCl SubutexBuprenorphine/Naloxone HCl SuboxoneBuprenorphine Transdermal Patch Suboxone Naltrexone HCl (oral and injectable) ReviaNaltrexone Microsphere

Injectable Suspension Vivitrol

If a patient has the Medi-Cal card, please inquire if they also have one of the following L.A. Care Plan Partner cards by calling AEVS at 1-800-456-2387 or L.A. Care Health Plan. It is unlawful to charge L.A. Care Medi-Cal members for their medications.

800.605.2556www.care1st.com

Pharmacy Reference Guide

Cin#:Member No.: Effective Date:Ipa/Medical Group:Physician:Physician Phone: