John Keller
 
 
 John Keller DOB: 1994/03/02 (32 yo M) Acc No. CR589032 
 [Doc Name: SAVANI 2017/10/07 BCBS] 
 Transaction ID: 53653988216 Transaction Date: 2015/28/03 10:26 am Customer ID: 5814935 
 John Keller Subscriber 
 MEMBER ID BZZ10581493501 
 Other Blue Plans 
 DOB 1994/03/02 
 GENDER Male 
 PLAN / COVERAGE DATE 2020/30/11 - 2017/17/10 
 DATE OF SERVICE 2020/19/12 
 Either the patient's ID, name, date of birth, or address in the response does not match the information sent in the request. The 
 response reflects the correct information. To avoid future errors in submission, please update this information in your computer system 
 Subscriber Information 
 221 James L Taylor Rd 
 PLAN NUMBER Facets 
 PRIOR ID NUMBER BZZ103459047 
 Plan / Product Information 
 ACTIVE COVERAGE 
 INDIVIDUAL 
 INSURANCE TYPE Preferred Provider Organization (PPO) 
 PLAN / PRODUCT 
 Blue Options 
 Members 18 and over with A1c between 5.7 and 6.1 without Type 2 Diabetes diagnosis are eligible for Virta Diabetes Prevention. 
 Members 18 and older with Type 2 Diabetes are eligible for Virta Diabetes Reversal 
 Service Types 
 Health Benefit Plan Coverage 
 ACTIVE COVERAGE 
 Infertility 
 ACTIVE COVERAGE 
 Preventive Drugs 
 Service Types 
 Pharmacy 
 ACTIVE COVERAGE 
 INDIVIDUAL 
 ACTIVE COVERAGE 
 Smoking Cessation 180 Day Supply Limit 
 ACTIVE COVERAGE 
 Service Types 
 Pharmacy 
 John Keller DOB: 1994/03/02 (32 yo M) Acc No. CR589032 
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