4. BENEFITS COVERAGE
Once a year
Once a year
women
Once a year
Once a year
Once a year
anemia
children
children
BENEFITS COVERAGE
children
in children
older
Once a year
and older
children
children
BENEFITS COVERAGE
FreedomCare Enrollment Guide Page 3
5. Your member ID card
Now that you are enrolled in FreedomCare, you will
receive your ID card detailed below. Your card
doctor/provider. Make sure to present your
package can bring you to a healthier lifestyle and how you have fully
important things in life.
available for you to purchase.
To locate a participating provider please call 844-657-1575
Discount Prescriptions
Employer Name
Group #: 2014000
Name: John A Doe
Member ID#: 2014000XXXXX
RX Bin#: 247007
RX Group#: 2014000 RxBin 610268
PCN PHXD
RxGRP FREEDOM
Locate a provider in your network.
Front Back
For Provider Use Only
Provider should verify eligibility before providing treatment.
Provider Services: 844-798-4878
Mail completed claim forms to
Red Rock Management Services, LLC
5130 South Fort Apache #215-365
Las Vegas, NV 89148
Member Services: 844-657-1575
Pharmacy Services: 844-657-1575
Call this number to speak with a member
Call this number to speak with a the
pharmacy help desk.
FreedomCare Enrollment Guide Page 4
7. To learn more about enrolling in the Minimum Value Plan,
please call 844-300-6497 (toll free)
You are being offered an Affordable Care Act
compliant health plan that is affordable and meets
minimum value. This offer of coverage is your
opportunity to enroll in an eligible employer
sponsored plan, or to decline coverage.
Please note that this offer of coverage does not
extend to your spouse. This offer of coverage is
made to employees and dependents as mandated
by the Affordable Care Act.
This offer of coverage was made to you as an
adequate notice and representation of the offer of
coverage.
You have fifteen (15) days to enroll in this eligible
employer sponsored plan which is a reasonable
period of time in which to accept to enroll or to
decline coverage. There are NO conditions on this
offer of coverage.
Affordability Notice
Our Minimum Value Plan is affordable under the
Affordable Care Act with the employee portion of
the premium totaling 9.5% of a monthly amount
determined as the federal poverty line for a single
individual for the applicable calendar year, divided
by 12. This amount increases each year according
to the federal poverty scale. Since this amount will
vary based on rate of pay, please call the
enrollment center listed below to learn more.
Minimum Value Plan
FreedomCare Enrollment Guide Page 6
8. Deductible Coinsurance Out of Pocket
Network Non-Network Network Non-Network Network Non-Network
$6,350 Not Covered 100% 0% $6,350 Not Covered
$6,350 Not Covered 100% 0% $6,350 Not Covered
MAJOR MEDICAL BENEFITS Network Non-Network
Not Covered
PCP, Urgent Car st
Not Covered
Not Covered
Rx Coverage
(Generic & Preferred Br
$6,350 Not Covered
Not Covered
Ment avior stance Not Covered
Imaging (CT/PET Sc Not Covered
Not Covered
-
P sic rap
Not Covered
Services
Not Covered
Not Covered
rsing F Not Covered
(e. ator rger nt
Not Covered
Services
Not Covered
ted ted
FreedomCare Enrollment Guide Page 7
10. FreedomCare Enrollment Guide Page 9
To locate a participating provider please call 844-657-1575
Discount Prescriptions
Employer Name
Group #: 2014000
Name: John A Doe
Member ID#: 2014000XXXXX
RX Bin#: 247007
RX Group#: 2014000 RxBin 610268
PCN PHXD
RxGRP FREEDOM
