Jason Jordan
611 lines
25 KiB
XML
611 lines
25 KiB
XML
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<text><![CDATA[Eligibility]]></text>
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<text><![CDATA[Administered by:
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Britton Benefit Services, LLC
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604 North Queen Street
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Kinston, NC 28502
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1.800.676.1182]]></text>
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<text><![CDATA[To confirm eligibility, verify benefits,
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or check claim:
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]]></text>
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<text><![CDATA[Call:
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1.800.676.1182 (8am – 5pm)
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Online:
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www.bbstpa.com (24/7)
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This card does not guarantee
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eligibility or payment
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<rectangle>
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||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
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<text><![CDATA[Pharmacy Plan]]></text>
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<font size="6" isBold="true"/>
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<font size="6" isBold="true"/>
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<text><![CDATA[Name:]]></text>
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<font size="6" isBold="true"/>
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<text><![CDATA[Member Id:]]></text>
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<font size="6" isBold="true"/>
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<text><![CDATA[Effective Date:]]></text>
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<textElement>
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<font size="6" isBold="true"/>
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</textElement>
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<text><![CDATA[Division:]]></text>
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<textField>
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<textElement>
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<font size="6"/>
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</textElement>
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<textFieldExpression><![CDATA[$F{MedicalGroupNum}]]></textFieldExpression>
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</textField>
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<textField>
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<reportElement uuid="c2877613-bc27-4175-b080-5ab67f1d781c" x="346" y="23" width="88" height="8"/>
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<textElement>
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<font size="6"/>
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<textFieldExpression><![CDATA[$F{FullName}]]></textFieldExpression>
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<textElement>
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||
<font size="6"/>
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</textElement>
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<textFieldExpression><![CDATA[$F{PBEntityKey}]]></textFieldExpression>
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<textField>
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||
<textElement>
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||
<font size="6"/>
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||
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<textFieldExpression><![CDATA[$F{MedicalEffDate}]]></textFieldExpression>
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||
<textElement>
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||
<font size="6"/>
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||
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<textFieldExpression><![CDATA[$F{Division}]]></textFieldExpression>
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<reportElement uuid="cf1ce1ca-5cef-436c-b2d6-26bd3e1015b4" x="304" y="61" width="76" height="8"/>
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||
<textElement>
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||
<font size="6" isBold="true"/>
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||
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||
<text><![CDATA[Covered Dependents:]]></text>
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||
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||
<textField>
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||
<reportElement uuid="848389f8-98f1-41da-962e-cc29aeac91d1" x="305" y="67" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
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||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent1}]]></textFieldExpression>
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<textField>
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||
<reportElement uuid="adee7873-b80c-4be4-9568-533471bab640" x="305" y="74" width="63" height="7"/>
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||
<textElement>
|
||
<font size="5"/>
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||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent2}]]></textFieldExpression>
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||
</textField>
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||
<textField>
|
||
<reportElement uuid="53ed1fe8-89ed-42a2-98bb-9ad75418f543" x="305" y="81" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="07c29443-8589-4e0f-a758-b69a34f38b07" x="371" y="67" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent4}]]></textFieldExpression>
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||
</textField>
|
||
<textField>
|
||
<reportElement uuid="f906328d-53c5-4bb7-b4d4-4eba2261adfb" x="371" y="74" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
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|
||
<textFieldExpression><![CDATA[$F{Dependent5}]]></textFieldExpression>
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||
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<reportElement uuid="a15671c2-f677-4def-9d42-1e0553d43010" x="371" y="81" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
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|
||
<textFieldExpression><![CDATA[$F{Dependent6}]]></textFieldExpression>
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||
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|
||
<image scaleImage="RetainShape">
|
||
<reportElement uuid="36c204c6-c2f7-4613-863f-332cf50ff6cc" x="358" y="101" width="76" height="23"/>
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<imageExpression><![CDATA["C:\\images\\FairRxOs.jpg"]]></imageExpression>
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|
||
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|
||
<font size="5" isBold="true"/>
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||
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|
||
<text><![CDATA[RX Bin:]]></text>
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||
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||
<staticText>
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||
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||
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|
||
<font size="5" isBold="true"/>
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||
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||
<text><![CDATA[RX PCN:]]></text>
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||
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||
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|
||
<reportElement uuid="4534f9a0-901a-402c-86ba-0b3109370e53" x="304" y="124" width="31" height="8"/>
|
||
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|
||
<font size="5" isBold="true"/>
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||
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||
<text><![CDATA[RX GRP:]]></text>
|
||
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|
||
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|
||
<reportElement uuid="abd7fb37-b19a-4691-869c-28a8c0b326ce" x="331" y="104" width="27" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[021841]]></text>
|
||
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|
||
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|
||
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|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[18000405]]></text>
|
||
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|
||
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|
||
<reportElement uuid="709713dc-5f48-40dc-957c-9f015b376b41" x="331" y="124" width="49" height="8"/>
|
||
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|
||
<font size="5" isBold="true"/>
|
||
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|
||
<textFieldExpression><![CDATA[$F{RXGroupID}]]></textFieldExpression>
|
||
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|
||
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|
||
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|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
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|
||
<text><![CDATA[Member Services:]]></text>
|
||
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|
||
<textField>
|
||
<reportElement uuid="0bce3d0c-c01b-4dfd-9638-19b94d75e73e" x="361" y="124" width="73" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="5" isBold="true"/>
|
||
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|
||
<textFieldExpression><![CDATA[$F{WebUrl}]]></textFieldExpression>
|
||
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|
||
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|
||
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|
||
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|
||
<font size="5" isBold="true"/>
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||
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||
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|
||
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|
||
<font size="6"/>
|
||
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|
||
<text><![CDATA[Pre-certification is required for
|
||
Inpatient Hospitalization
|
||
Call MedCost 1.800.722.2157
|
||
]]></text>
|
||
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|
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||
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||
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||
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||
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||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
<font size="7"/>
|
||
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|
||
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|
||
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|
||
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|
||
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|
||
<textElement textAlignment="Center">
|
||
<font size="5"/>
|
||
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|
||
<text><![CDATA[(800-824-7406) for provider look-up
|
||
www.medcost.com]]></text>
|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
||
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|
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|
||
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