Front of Card Back of Card

Your
Texas Members: Keep this card with you. This is your medical ID card. Show this card to your
Benefits doctor when you get services. To learn more, go to www.YourTexasBenefits.com or
call 800-252-8263.
Member Name :
Miembros: Lleve esta tarjeta con usted. Muestre esta tarjeta a su doctor al recibir
KARESSICA GRANT servicios. Para más información, vaya a www.YourTexasBenefits.com o llame al
800-252-8263.
Member ID: Note to Provider:
Ask this member for the card from their Medicaid THIS CARD DOESN'T GUARANTEE ELIGIBILITY OR PAYMENT FOR SERVICES.
530447931 health plan. Providers should use that card for billing
Issuer ID: help. No health plan card?
Date Card Sent: Providers: To verify eligibility, call 800-925-9126. Non-managed care pharmacy claims
Pharmacists can use the non-managed care billing
610258 01/13/2021 information on the back of this card. assistance: 800-435-4165

Non-managed care Rx billing: RxBIN: 610084 / RxPCN: MEDICAID / RxGRP: DRTXPROD

My Information
Member ID: 530447931 Date of Birth: 09/28/1991
Program Name: STAR Medicare Coverage: N

Name: KARESSICA GRANT Gender: F Medicare Beneficiary Identifier:

Medical Plan Dental Plan Pharmacy Benefits

Plan Name: SUPERIOR HEALTHPLAN Plan Name: RxBIN: 008019

Plan Phone: 8776444494 Plan Phone: RxPCN: SHP

RxGRP: 18011
Call this number if you have questions about your doctor or Call this number if you have questions about your dentist or
health services. dental services.
Main Doctor
Name: LONGVIEW WELLNESS CENTER INC Phone: 9037582610

Address: 1107 E MARSHALL AVE, LONGVIEW, TX 75601-5602

This document does not guarantee eligibility or payment for services.

To learn more, call 800-252-8263.