P.O.

Box 44236

Pramodkumar Ray
Individual Under 65 Plans

Jacksonville, FL 32231-4236

13642 EMERALDVIEW DR
ORLANDO, FL 32828-8412
Enrollment & Billing Department

Pramodkumar Ray BC 090 BS 590

Member Number Rx Bin 012833
VMAH17420898 PCN FLBC
Plan Number 1604C Group Number 99999

Pramodkumar Ray BC 090 BS 590

Member Number Rx Bin 012833
VMAH17420898 PCN FLBC
Plan Number 1604C Group Number 99999
 and Blue Shield Association that permits Florida Blue HMO
contract pursuant to which the card is issued constitutes an
agreement solely between the contract holder and Florida

corporation operating under a license from the Blue Cross

© 2016 Florida Blue HMO is the trade name of Health Options, Inc., an HMO

Blue HMO, and that Florida Blue HMO is an independent

By accepting this card and any benefits to which this card

to use the Blue Cross and Blue Shield Names and Service
subsidiary of Blue Cross and Blue Shield of Florida, Inc. These companies are

entitles the holder, the holder acknowledges that the

Independent Licensees of the Blue Cross and Blue Shield Association.

Marks in the State of Florida.

floridablue.com Printed:12/12/16
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Customer Service/Pre-Certification:
1-855-692-5830 TTY#: 711
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Notice to Participating Provider: Some Florida providers use Availity or send
services require authorization and/or pre- claims to:
certification. For authorization, contact the Health-P.O. Box 1798 Jacksonville, FL 32231
patient's PCP. For pre-certification, contact Vision-P.O. Box 1525 Latham, NY 12110-1525
the number above. Emergency services and Dental-P.O. Box 1047 Elk Grove Village, IL
care in the emergency room do not require 60009-1047
authorization; for followup care contact the HMO coverage is offered by Health
patient's PCP. Options, Inc., DBA Florida Blue HMO,
Pharmacies: For claims submission and other an affiliate of Blue Cross and Blue Shield
helpful information, visit floridablue.com. of Florida, Inc., DBA Florida Blue. These
companies are Independent Licensees of
Out-of-State Providers: Submit all claims to the Blue Cross and Blue Shield Association.
the Blue Cross and Blue Shield Plan serving
your area. Possession of this card does not guarantee
eligibility for benefits.
This plan is a Health Maintenance Organization.
To locate a participating provider outside of
Florida, visit bcbs.com.
floridablue.com Printed:12/12/16
Printed: <00/00/00>
For quicker service - Login at floridablue.com
Customer Service/Pre-Certification:
1-855-692-5830 TTY#: 711
Inicie sesión/Regístrese en floridablue.com
Notice to Participating Provider: Some Florida providers use Availity or send
services require authorization and/or pre- claims to:
certification. For authorization, contact the Health-P.O. Box 1798 Jacksonville, FL 32231
patient's PCP. For pre-certification, contact Vision-P.O. Box 1525 Latham, NY 12110-1525
the number above. Emergency services and Dental-P.O. Box 1047 Elk Grove Village, IL
care in the emergency room do not require 60009-1047
authorization; for followup care contact the HMO coverage is offered by Health
patient's PCP. Options, Inc., DBA Florida Blue HMO,
Pharmacies: For claims submission and other an affiliate of Blue Cross and Blue Shield
helpful information, visit floridablue.com. of Florida, Inc., DBA Florida Blue. These
companies are Independent Licensees of
Out-of-State Providers: Submit all claims to the Blue Cross and Blue Shield Association.
the Blue Cross and Blue Shield Plan serving
your area. Possession of this card does not guarantee
eligibility for benefits.
This plan is a Health Maintenance Organization.
To locate a participating provider outside of
Florida, visit bcbs.com.