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