Transaction ID: 11592904531 Transaction Date: Aug 12, 2019 4:05 pm Customer ID: 455214

ALLARD, SEBASTIEN Subscriber

MEMBER ID XDP867A78151
DOB Jun 16, 1971
GENDER Male
PLAN / COVERAGE DATE May 01, 2019 - Dec 31, 9999
DATE OF SERVICE Aug 12, 2019

FOR ALL SERVICES WITH HSA PLANS, THE DEDUCTIBLE MUST BE MET PRIOR TO APPLYING ANY COPAYMENT.
REMINDER, PATIENT MAY HAVE HRA/HSA DOLLARS THAT CAN BE APPLIED TOWARDS THEIR DEDUCTIBLE AND OUT OF
POCKET EXPENSES.

Subscriber Information
4239 E MASSACHUSETTS ST CONTRACT CODE / CASE NUMBER 3SAR
LONG BEACH, CA 90814 GROUP NUMBER 281456M011
MEMBER ID XDP867A78151 PLAN SPONSOR NAME C W DRIVER INCORPORATED
PLAN NAME C W DRIVER INCORPORATED
PLAN NUMBER 040

Plan / Product Information

ACTIVE COVERAGE EMPLOYEE AND SPOUSE

INSURANCE TYPE Preferred Provider Organization (PPO)

PLAN / PRODUCT CA GENERIC HLTH INCENTIVE ACCOUNT PLUS

Service Types
Health Benefit Plan Coverage

Payer Details Other or Additional Payers

PAYER ANTHEM BLUE CROSS SERVICE TYPE Health Benefit Plan Coverage
PAYER ID 040 MEMBER IDENTIFICATION NUMBER 896A62196
COB DATE Jan 01, 2016 - Jun 20, 2020

Provider Details
REQUESTING PROVIDER

NAME RUSSO, MICHAEL

NPI 1801824362

Benefit Disclaimer
UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL
CONTRACT LIMITATIONS AND THE MEMBERS ELIGIBILITY STATUS ON THE DATE OF SERVICE. FOR ANY QUESTIONS PLEASE CALL PHONE
NUMBER ON BACK OF MEMBERS CARD.
Coverage and Benefits Information

Chiropractic - 33

Co-Payment - Chiropractic
IN NETWORK INDIVIDUAL $30.00 Visit

Co-Insurance - Chiropractic
OUT OF NETWORK INDIVIDUAL 40 %

Deductible - Chiropractic
IN NETWORK INDIVIDUAL $0.00 Calendar Year

BENEFIT DATE May 01, 2019 - Dec 31, 2019

Limitations - Chiropractic
NETWORK NOT APPLICABLE 30 Visits / Calendar Year

NETWORK NOT APPLICABLE 30 Visits / Remaining

Health Benefit Plan Coverage - 30

ACTIVE COVERAGE EMPLOYEE AND SPOUSE

INSURANCE TYPE Preferred Provider Organization (PPO)

PLAN / PRODUCT CA GENERIC HLTH INCENTIVE ACCOUNT PLUS

Benefit Description - Health Benefit Plan Coverage

NETWORK NOT APPLICABLE EMPLOYEE AND SPOUSE $1,340.00 Calendar Year

HRA ACCOUNT

NETWORK NOT APPLICABLE EMPLOYEE AND SPOUSE $1,340.00 Remaining

HRA ACCOUNT

NETWORK NOT APPLICABLE

THIS PATIENT FALLS UNDER THE DEPARTMENT OF

MANAGED HEALTH CARE OVERSIGHT
Additional Payers - Health Benefit Plan Coverage
MEMBER IDENTIFICATION NUMBER 896A62196
COB DATE Jan 01, 2016 - Jun 20, 2020

Deductible - Health Benefit Plan Coverage

IN NETWORK INDIVIDUAL $2,000.00 Calendar Year

COVERAGE DATE May 01, 2019 - Dec 31, 2019

$2,000.00 Remaining

The Lesser of the individual or family deductible remaining

amount applies

IN NETWORK FAMILY $4,000.00 Calendar Year

COVERAGE DATE May 01, 2019 - Dec 31, 2019

$4,000.00 Remaining

The Lesser of the individual or family deductible remaining

amount applies

OUT OF NETWORK INDIVIDUAL $6,000.00 Calendar Year

COVERAGE DATE May 01, 2019 - Dec 31, 2019

$6,000.00 Remaining

The Lesser of the individual or family deductible remaining

amount applies

OUT OF NETWORK FAMILY $12,000.00 Calendar Year

COVERAGE DATE May 01, 2019 - Dec 31, 2019

$12,000.00 Remaining

The Lesser of the individual or family deductible remaining

amount applies

Out of Pocket (Stop Loss) - Health Benefit Plan Coverage

IN NETWORK INDIVIDUAL $5,000.00 Calendar Year
$4,820.00 Remaining

IN NETWORK FAMILY $10,000.00 Calendar Year

$9,820.00 Remaining

OUT OF NETWORK INDIVIDUAL $15,000.00 Calendar Year

$15,000.00 Remaining

OUT OF NETWORK FAMILY $30,000.00 Calendar Year

$30,000.00 Remaining