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TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
DESERET PREMIER
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR CONTRACTED PROVIDER COPAYMENTS:Primary Care ...........................$15Specialist ................................$25Urgent Care ............................$35Emergency Room ...................$75
Card issue date: 00/00/00
Medical Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
• To
find c
ontra
cted p
rovide
rs in
your
area
: ww
w.dm
ba.co
m
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS
P.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
DESERET SELECT
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR CONTRACTED PROVIDER COPAYMENTS:Primary Care ...........................$15Specialist ................................$25Urgent Care ............................$35Emergency Room ...................$75
Card issue date: 00/00/00
Medical Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
• To
find c
ontra
cted p
rovide
rs in
your
area
: ww
w.dm
ba.co
m
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS
P.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
DESERET CHOICE HAWAII
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR CONTRACTED PROVIDER COPAYMENTS:Primary Care ...........................$15Specialist ................................$20Urgent Care ............................$25Emergency Room ...................$75
Card issue date: 00/00/00
Medical Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
808-6
75-39
72 (H
awaii
), 808
-675-4
873 (
Hawa
ii),
801-5
78-56
00, o
r 800
-777-3
622
•Fo
r pres
cript
ion qu
estio
ns:
801-4
17-97
22 or
877-8
79-97
22•
To fin
d con
tracte
d prov
iders
in yo
ur ar
ea:
www.
dmba
.com
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS
P.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
DMBA: 2017 IDENTIFICATION CARDS
EMPLOYER PLANS
FRONT BACK
FRONT BACK
FRONT BACK
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
DESERET PROTECT
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR CONTRACTED PROVIDER COPAYMENTS:Primary Care ...........................$15Specialist ................................$30Urgent Care ............................$40Emergency Room ...................$75
Card issue date: 00/00/00
Medical Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
• To
find c
ontra
cted p
rovide
rs in
your
area
: ww
w.dm
ba.co
m
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS
P.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
DESERET VALUE
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR CONTRACTED PROVIDER COPAYMENTS:Primary Care ...........................$15Specialist ................................$25Urgent Care ............................$35Emergency Room ...................$75
Card issue date: 00/00/00
Medical Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
• To
find c
ontra
cted p
rovide
rs in
your
area
: ww
w.dm
ba.co
m
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS
P.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
DMBA: 2017 IDENTIFICATION CARDS (CONTINUED)
EMPLOYER PLANS (CONTINUED)
FRONT BACK
FRONT BACK
CMS-S3875 0802DESERET ALLIANCE
Name JOHN DOE
DMBA ID 00000
Issuer DMBA
RxBIN 015574
RxPCN ASPROD1
RxGroup 00000
Rx ID 00000
DESERET ALLIANCE COPAYMENTS:Primary Care ................... $15Specialist ........................ $15Urgent Care .................... $15Emergency Room ........... $50
Card issue date: 00/00/00
Medicare Supplement Plan & Rx ID Card
TO PURCHASE PRESCRIPTION DRUGS, USE THIS ID CARD AT THE PHARMACY.
Parti
cipan
t:• Y
ou m
ust re
ceive
servi
ces f
rom
Med
icare-
eligib
le pr
ovide
rs.• F
or ge
neral
bene
fit qu
estio
ns:
801-5
78-56
00 or
800-7
77-36
22• F
or pr
escri
ption
ques
tions
: Con
tact
Gran
ite Al
lianc
e dire
ctly.
801-5
03-38
50
or 85
5-586
-2573
or TT
Y use
rs ca
ll 711
or
visit
DM
BA’s w
ebsit
e at w
ww.dm
ba.
com
Prov
ider
s:• D
esere
t Allia
nce i
s a M
edica
re su
pplem
ent p
lan fo
r DM
BA pa
rticip
ants
on M
edica
re. Se
nd al
l clai
ms t
o you
r loc
al M
edica
re ca
rrier.
• For
pharm
acy t
echn
ical s
uppo
rt:
801-5
03-38
60 or
855-5
86-25
74• Y
ou m
ust b
ill M
edica
re—d
o not
bill
DMBA
.• F
or qu
estio
ns ab
out s
upple
men
tal
bene
fits no
t cov
ered b
y Med
icare,
call
801-5
78-56
00 or
80
0-777
-3622
or vi
sit w
ww.dm
ba.co
m/
prov
ider.
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
DMBA: 2017 IDENTIFICATION CARDS (CONTINUED)
MEDICARE SUPPLEMENT PLANS
FRONT BACK
DESERET ALLIANCE
Name JOHN DOE
Issuer DMBA
ID No. 000000
RxBin 610245
RxPCN 05490000
RxGroup 000000
DESERET ALLIANCE COPAYMENTS:Primary Care ................... $15Specialist ........................ $15Urgent Care .................... $15Emergency Room ........... $50
Card issue date: 00/00/00
Medicare Supplement Plan ID Card
ADDITIONAL NETWORKS
TO PURCHASE PRESCRIPTION DRUGS, USE THIS ID CARD AT THE PHARMACY.
TM
Parti
cipan
t:• Y
ou m
ust re
ceive
servi
ces f
rom
Med
icare-
eligib
le pr
ovide
rs.• F
or ge
neral
bene
fit qu
estio
ns:
801-5
78-56
00 or
800-7
77-36
22• F
or pr
escri
ption
ques
tions
: Con
tact V
Rx
direc
tly. 8
01-41
7-972
2 or 8
77-87
9-97
22 or
visit
DM
BA’s w
ebsit
e at w
ww.
dmba
.com
Prov
ider
s:• D
esere
t Allia
nce i
s a M
edica
re su
pplem
ent p
lan fo
r DM
BA pa
rticip
ants
on M
edica
re. Se
nd al
l clai
ms t
o you
r loc
al M
edica
re ca
rrier.
• You
mus
t bill
Med
icare
—do n
ot bi
ll DM
BA.
• For
ques
tions
abou
t sup
plem
ental
be
nefits
not c
overe
d by M
edica
re, ca
ll 80
1-578
-5600
or
800-7
77-36
22 or
visit
www
.dmba
.com
/pr
ovide
r.
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
FRONT BACK
TM
Name <<Card Name>>
Issuer DMBA
DMBA ID <<ID1>>
Group <<Group1>>
RxBin 610245
PCN 05490000
Card issue date: <<Date>>
Health Plan ID Card
PART
ICIP
ANT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
61•
For p
rescri
ption
ques
tions
: 80
1-578
-5661
Or
call V
Rx 24
hour
s a da
y: 80
1-417
-9722
or 87
7-879
-9722
PROV
IDER
:•
To ve
rify y
our p
atien
t’s el
igibil
ity,
call 8
01-57
8-566
1•
Send
all m
edica
l and
dent
al cla
ims t
o:DM
BA Pl
an Z
P.O. B
ox 24
30
Salt L
ake C
ity, U
T 841
10-24
30
PLAN Z
FRONT BACK
STUDENT MEDICAL BENEFIT
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR STUDENT COPAYMENTS:Physician at SHC .....................$10Physician outside SHC ............$25Emergency Room ...................$50Hospital ............................... $200Covered Rx .............................30%
TM
BYU-HAWAII
All Other Areas:
Card issue date: 00/00/00
Medical & Rx Benefit ID
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
STUD
ENT:
•Fo
r ben
efit q
uesti
ons:
808-6
75-39
72, 8
01-57
8-560
0, or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
8-675
-3972
, 801
-417-9
722,
or 87
7-879
-9722
•W
hene
ver p
ossib
le, re
ceive
care
at a p
artici
patin
g stu
dent
healt
h cen
ter:
BYU-
Hawa
ii #19
16, 5
5-220
Kulan
ui Str
eet
Laie,
HI 9
6762
808-6
75-35
10•
To fin
d con
tracte
d prov
iders
in yo
ur ar
ea:
www.
dmba
.com
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 808
-375-3
972 o
r 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS, P
.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
STUDENT HEALTH PLAN
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR STUDENT COPAYMENTS:Physician at SHC ....................$10Physician outside SHC ...........$25Urgent Care ............................$25Emergency Room ...................$50Covered Rx ............................20%
BYU-IDAHO
Card issue date: 00/00/00
Medical & Rx Benefit ID
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
STUD
ENT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
•W
hene
ver p
ossib
le, re
ceive
care
at a p
artici
patin
g stu
dent
healt
h cen
ter:
100 S
tude
nt H
ealth
Cent
er, BY
U-Ida
hoRe
xbur
g, ID
8346
0-201
020
8-496
-9330
•To
find c
ontra
cted p
rovide
rs in
your
area
: ww
w.dm
ba.co
m
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS, P
.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
TM
All Other Areas:
ADDITIONAL NETWORKSUtah, Hawaii, & Southeast Idaho:
STUDENT HEALTH PLAN
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
UHC ID 00000
UHC Group 00000
RxBin 610245
PCN 05490000
YOUR STUDENT COPAYMENTS:Physician at SHC .............$10/$15Physician outside SHC ............$25Urgent Care/ER ...............$25/$50Covered Rx at SHC .................20%Covered Rx outside SHC ........40%
BYU & LDS BUSINESS COLLEGE
Card issue date: 00/00/00
Medical & Rx Benefit ID
STUD
ENT:
•Fo
r ben
efit q
uesti
ons:
801-5
78-56
00 or
800-7
77-36
22•
For p
rescri
ption
ques
tions
: 80
1-417
-9722
or 87
7-879
-9722
•W
hene
ver p
ossib
le, re
ceive
care
at a p
artici
patin
g stu
dent
healt
h cen
ter:
-BY
U Stu
dent
Hea
lth Ce
nter:
801-4
22-51
56-
Mad
sen H
ealth
Cent
er: 80
1-581
-8000
-Su
gar H
ouse
Hea
lth Ce
nter:
801-5
81-20
00•
To fin
d con
tracte
d prov
iders
in yo
ur ar
ea:
www.
dmba
.com
•Fo
r prea
utho
rizati
on re
quire
men
ts, se
e you
r Stu
dent
Pla
n Han
dboo
k.
PROV
IDER
S:Ut
ah, H
awaii
, & So
uthe
ast I
daho
:•
Befor
e prov
iding
inpa
tient
care
or to
verif
y elig
ibility
, ca
ll 800
-777-3
622.
• Se
nd al
l med
ical c
laim
s to:
DMBA
P.O
. Box
4553
0 Sa
lt Lak
e City
, UT 8
4145
-0530
All O
ther
Area
s:•
Befor
e prov
iding
inpa
tient
care,
call 8
88-70
5-035
8.•
To ve
rify y
our p
atien
t’s el
igibil
ity:
www.
uhis.
com
or 88
8-830
-0179
•Se
nd al
l med
ical c
laim
s to:
EDI #
3902
6, UH
SS, P
.O. B
ox 30
783
Salt L
ake C
ity, U
T 841
30-07
83
THIS CARD DOES NOT GUARANTEE BENEFITS OR COVERAGE.
DMBA: 2017 IDENTIFICATION CARDS (CONTINUED)
STUDENT PLANS
FRONT BACK
FRONT BACK
FRONT BACK
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
RxBin 610245
PCN 05490000YOUR COPAYMENTS:Primary Care ...........................$10Specialist ................................$10Urgent Care ............................$10Emergency Room ...................$10Prescriptions ...........................$10
TM
Card issue date: 00/00/00
Medical Services ID Card To missionaries:• If you are covered by your family’s health
insurance plan, please present that plan’s ID card as your primary insurance, and this card as secondary. If you are not covered by your family’s health insurance plan, this card may be used for primary payment.
To all providers:• Authorization/eligibility for care or
pharmacy questions: 800-777-1647 • Send all claims to:
Missionary MedicalP.O. Box 45730Salt Lake City, UT 84145-0730
Payments are made from charitable contributions that are both gratuitous
and voluntary from:
Name JOHN DOE
Issuer DMBA
ID 00000
Group 00000
Rx ID 00000
RxBin 610245
PCN 05490000
Card issue date: 00/00/00
Medical Services ID Card
TM
To mission presidents:• For additional information, scan this QR code• Or visit www.dmba.com/mpcard
To all providers:• Authorization/eligibility for outpatient care:
888-830-0179• Authorization for inpatient care: 888-705-0358• Send all claims to:
EDI #39026UnitedHealthcare Shared ServicesP.O. Box 30783Salt Lake City, UT 84130-0783
• After hours or for pharmacy questions, call the plan sponsor: 800-777-1647
Payments are made from charitable contributions that are both gratuitous
and voluntary from:
Name JOHN DOE
Issuer DMBA
DMBA ID 00000
Group 00000
RxBin 610245
PCN 05490000
Medical Services ID Card
Card issue date: 00/00/00
Medical Services ID Card
TM
To mission presidents:• For additional information, scan this QR
code• Or visit www.dmba.com/mpcard
To all providers:• Authorization/eligibility for care or
pharmacy questions: 800-777-1647• Send all medical claims to:
Missionary MedicalP.O. Box 45730Salt Lake City, UT 84145-0730
Payments are made from charitable contributions that are both gratuitous
and voluntary from:
DMBA: 2017 IDENTIFICATION CARDS (CONTINUED)
MISSION PRESIDENTS
FRONT BACK
FRONT BACK
FRONT BACK
MISSIONARY MEDICAL PLANS
TM
Name JOHN DOE
Issuer DMBA
ID 00000
Group 00000
Rx ID 00000
RxBin 610245
PCN 05490000 YOUR COPAYMENTS:Primary Care ...........................$10Specialist ................................$10Urgent Care ............................$10Emergency Room ...................$10Prescriptions ...........................$10Card issue date: 00/00/00
Medical Services ID Card To missionaries:• If you are covered by your family’s health
insurance plan, please present that plan’s IDcard as your primary insurance, and this card as secondary. If you are not covered by your family’s health insurance plan, this card may be used for primary payment.
To all providers:• Authorization/eligibility for outpatient care:
888-830-0179• Authorization for inpatient care: 888-705-0358• Send all medical claims to:
EDI #39026UnitedHealthcare Shared ServicesP.O. Box 30783Salt Lake City, UT 84130-0783
• After hours or for pharmacy questions, call the plan sponsor: 800-777-1647
Payments are made from charitable contributions that are both gratuitous
and voluntary from:
DMBA: 2017 IDENTIFICATION CARDS (CONTINUED)
MISSIONARY MEDICAL PLANS (CONTINUED)
FRONT BACK