Bluchss BlueShield 1)chan PO Box 7344 Omega [6063117344 I immuon Hi Uzrmillx i I11 Is not a ELIZABETH MORENO UPDA AI 1, IS VD OR ['Inim lnfomlallon Tom Billed: 517850.00 Panem Vamc 1) MORENO 1mm Benclils Approved: 511.110 Amount V01: Owe Pmn'der: 517850.110 FORMATION Sends: mm 11:11:11 \m Cnvurul Covered su\s1-1 1,111. va1der Pauenl Accuum 30.: NJZUA I ahommry Sun/1m: 1117211711. 29751111 2951.111. 111 boralcry s" 1112115 6675.170 41,711.34 (11 hnrmury htrvu. 111 2117111 1511.01) 1144 24 (11 Laboratory Serviccs 1117111 11: 1711111111 169A 74 (11 5mm, 1117211 In 212 uu 212157 111 Services 01211715 425.1111 419.32 111 luburdlory Sen/ices 111 1145 4251111 41111111 (11 Same. 1501111 1144.211 (11 1 nhurdlur) Sen/1w: 1117211711, an 1144 12 (1) laboratory Services 0172846 12751111 [269.24 (11 labormury Swim n1721716 425.00 419 72 (1) Laboratory 111211-11. 425.1111 AZIJS (1) 1417mm, 01 21115 ?2<11u 412.711 (11 laboratory bL'rViL'L-s 111 23711. 11231111 4119M (11 1171111: 3 1 71150.01 5 1 771191111 51011.92 COVERAGE INFORMATION Tums "711511.110 317749.111 $101191 neaucuum \unrl'aruclpaling Pmider ()pdun Program mum-11mg 11111>>: My Tom Doducfinns 111111.92 1'an 11mm Appravnd 30.00 Amman 11m. M-y 0w: Providu 317115111111 4 Dwmono/Ilmm (m yum. ('wvumnon A 1.1m 11mm <