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1 PHARMACY POLICY Opioid Analgesics Effective Date: June 1, 2017 Last Revised: May 23, 2017 Replaces: N/A RELATED MEDICAL POLICIES: Pharmacologic Treatment of Neuropathy, Fibromyalgia and Seizure Disorders Medical Necessity Criteria for Medication Safety: Controlled Substances Utilization Service Program Medical Necessity Criteria for Compounded Medications Medical Necessity Criteria for Pharmacy Edits Select a hyperlink below to be directed to that section. POLICY CRITERIA CODING RELATED INFORMATION EVIDENCE REVIEW REFERENCES HISTORY Clicking this icon returns you to the hyperlinks menu above. Introduction Opioids are chemicals (natural or synthetic), which bind to receptors in the brain or body. Opioid medications can be used to manage certain types of pain when prescribed by and in consultation with a licensed healthcare professional. Examples of an opioid medication include: oxycodone, hydrocodone, and fentanyl. This policy describes coverage criteria for some of the commonly prescribed opioid medications. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. Policy Coverage Criteria Note: A copy of medical records history is required when submitting prior authorization requests for the drugs affected by this policy.

2 Drug Extended-release hydrocodone (Zohydro ER ) Medical Necessity Extended-release hydrocodone (Zohydro ER ) may be considered medically necessary for the labeled indication of the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Extended release hydrocodone bitartrate (Zohydro ER) may be covered when ALL of the following criteria are met: Treatment of severe chronic pain that requires around the clock opioid pain management AND Documented therapeutic failure of TWO long acting opioids (eg, fentanyl citrate, fentanyl transdermal, hydromorphone, morphine ER, OxyContin) AND Patient is not under the age of 19 years old AND Quantity is not over 60 capsules per 30 days AND In the event that a request is received that does not meet criteria for approval but is of a sufficiently high dose that would require tapering, a 3 month approval may be authorized to allow the provider time to reduce the dose to the allowed quantities above. These requests may be approved on a case by case basis and are subject to a clinical review for medical necessity. AND In the event where tapering cannot be achieved within a 3- months period, ALL of the following criteria must be met for approval to be granted: o Patient is being seen by a board certified pain specialist o Patient and the doctor have a pain management contract in place o Patient has had trials of other non-pharmacologic therapies, such as physical therapy, acupuncture, massage therapy, etc. o Chart notes must include (state-specific) Prescription Drug Page 2 of 11

3 Drug Extended-release oxycodone (OxyContin ) Medical Necessity Monitoring Program summary report (last 3 months) o Patient participates in urine drug screening tests (last 3 months) First-time approvals will be covered for a period of 3 to 6 months (case-dependent). For continuation of coverage beyond the first 3 or 6 months new case review will be required. o In addition, short term approvals may be given on a case by case basis when clinical rationale has been submitted by a provider indicating that a tapering dose is being attempted, and patient is expected to reach 120 Morphine Milligram Equivalent (MME) dosing by the end of the 3 months. These requests are subject to a clinical review for medical necessity. Extended-release oxycodone (OxyContin ) may be considered medically necessary for the labeled indication of the management of pain severe enough to require daily, aroundthe-clock, long-term opioid treatment and for which alternative treatment options are inadequate. Extended release oxycodone (OxyContin ) therapy should not exceed the following quantity limits: Three tablets per day of OxyContin 10 mg, 15 mg, 20 mg, 30 mg, 40 mg OR four tablets per day of OxyContin 60 mg and 80 mg. In the event that a request is received that does not meet criteria for approval but is of a sufficiently high dose that would require tapering, a 3 month approval may be authorized to allow the provider time to reduce the dose to the allowed quantities above. These requests may be approved on a case by case basis and are subject to a clinical review for medical necessity. In the event where tapering cannot be achieved within a 3- months period ALL of the following criteria must be met for approval to be granted: o Medication is being prescribed by or in consultation with a board certified pain specialist as defined by the American Page 3 of 11

4 Drug Transmucosal fentanyl citrate products Medical Necessity Board of Medical Specialties (ABMS), OR by a licensed health professional with extensive training/experience in pain management. o Patient and the doctor have a pain management contract in place o Patient has had trials of other non-pharmacologic therapies, such as physical therapy, acupuncture, massage therapy, etc. o Chart notes must include (state-specific) Prescription Drug Monitoring Program summary report (last 3 months) o Patient participates in urine drug screening tests (last 3 months) First-time approvals will be covered for a period of 3 to 6 months (case-dependent). For continuation of coverage beyond the first 3 or 6 months new case review will be required. o In addition, short term approvals may be given on a case by case basis when clinical rationale has been submitted by a provider indicating that a tapering dose is being attempted, and patient is expected to reach 120 Morphine Milligram Equivalent (MME) dosing by the end of the 3 months. These requests are subject to a clinical review for medical necessity. o Quantity limit requests that are the result of a lower strength tablet being used in multiples that could be achieved with a higher dose tablet (ie, three 20mg tablets versus one 60mg tablet) will not be approved. In certain circumstances, an approval may be given based on clinical rationale submitted and would be subject to a review for medical necessity. Transmucosal fentanyl citrate products (eg, Abstral, Actiq, Fentora, Lazanda, Onsolis, Subsys) may be considered medically necessary for the treatment of breakthrough cancer pain in adult patients with compromised oral intake or absorption. Page 4 of 11

5 Coding N/A Related Information Benefit Application This policy is managed through the Pharmacy benefit. It applies to all pharmacy benefit contracts that include Pharmacy Prior Authorization Edits. Evidence Review Description Analgesics are used to treat a wide variety of pain syndromes. Traditionally, these have been classified in three groups: acute pain, chronic cancer pain and chronic pain in non-cancer patients. Each requires a different approach. In acute pain the goal is to keep the patient comfortable while avoiding respiratory depression and minimizing the potential of opioid dependence. Oncology patients are managed to achieve the best functional balance of analgesia versus sedation. No maximum dose limits exist in this setting, while chronic noncancer pain should be managed with regimens that combine drugs from different pharmacologic classes to minimize opioid use, eg, antidepressants, NSAIDs or acetaminophen, muscle relaxants and anticonvulsants. This policy addresses one pharmacologic class: Opioids Long-acting opioids (OxyContin ) Immediate acting rescue medications: Transmucosal fentanyl citrate (Actiq, Fentora ) Page 5 of 11

6 Opioid Abuse Abuse of prescription opioid products is a growing concern. The 2006 National Survey on Drug Use and Health (NSDUH) found 4.7 million people used a prescription opioid for non-medical purposes in the month prior to the survey. More than 2 million per year are considered new illicit users of prescription opioids, a 5-fold increase from the 1980s. In 2007, more people > 12 years old began illicitly using opioids than marijuana, cocaine or any other illegal drug. In addition to abuse of opioids, prescriptions of opioids for pain are also increasing. From 1992 to 2002 prescriptions for opioids increased 154% while the US population increased 13%. Along with this increase in legitimate and illicit use of opioids has come an increase in ER visits and deaths due to opioids use. The public health surveillance system, Drug Abuse Warning System (DAWN), last published data on drug related emergency visits from 2008 and found the largest number of ER visits occurred with oxycodone combinations (105,214) followed by hydrocodone combinations (89,051) then methadone (63,629). These numbers have increased dramatically from 2004 with a 152% increase for oxycodone, 123% with hydrocodone and 73% with methadone (all p<0.05). The rationale for the ER visit (drug abuse, side effects etc.) was not included. An analysis of serious events from the FDA s adverse event reporting system found oxycodone was suspected in the largest number of deaths and serious nonfatal outcomes with 5,548 reports. The cause of the adverse event (drug abuse, side effects etc.) was not included. An analysis of deaths among Medicaid enrollees from overdose in Washington state from found methadone was involved in the most deaths (64%), followed by oxycodone (22.9%) and hydrocodone (13.9%). Adverse events related to methadone have increased 1800% from 1997 to 2004 with a 390% increase in fatalities during the same period. Most methadone deaths appear to be the result of accidental exposures, although more data is needed. While it is clear that use and adverse events with opioids are increasing, the data do not differentiate between events due to increased legitimate prescribing for pain and those due to illicit use. Additionally, as the number of total exposures to each drug is unknown, it is difficult to determine the risk associated with each drug due to lack of a meaningful denominator. In 2010, the Washington State Legislature passed a statute requiring professional boards to draft regulations managing high-dose opioid use, clearly recognized as a serious threat to public health. Page 6 of 11

7 Extended-release Oxycodone The purpose of the OxyContin quantity limit is fourfold: Reduce unnecessarily large quantities from being dispensed, thereby decreasing the likelihood of unnecessary tablets remaining in medicine cabinets where relatives and other visitors to the home could pilfer them. Remind prescribers to select a larger tablet size when increasing the dose, rather than ordering two tablets to be taken at one time. Serve as a warning signal is cases where a patient may be using part of the prescription nonmedically, or may be diverting pills for use by others for whom they were not prescribed. OxyContin is normally dosed every 12 hours and is designed to be administered as 2 tablets per day. In individuals with more rapid than normal clearance of oxycodone, or other unusual clinical circumstances, it is likely that 3 per day would be required. By setting the limit at 3, we allow for flexibility on the part of practitioners and their patients. OxyContin is available in tablet sizes of 10, 15, 20, 30, 40, 60 and 80 mg. When the 80mg tablet size is reached, the patient should be receiving 160mg/day. For cancer patients needing to go beyond this dose, the 4 tablet limit allows a further escalation to 320mg/day before approval of a quantity override would be needed. Exception for medical necessity will be routinely given when the patient is being treated for cancer pain and has reached the maximum dosage achievable with 4 tablets per day. Transmucosal Fentanyl Transmucosal fentanyl agents are potent analgesics approved for the treatment of breakthrough pain in opioid-treated and tolerant cancer patients. There is no fully published randomized controlled evidence for use of these products for non-cancer pain at this time. Availability of longer-term safety/tolerability data with Fentora is limited. Because lifethreatening respiratory depression could occur at any dose in opioid non-tolerant patients, Fentora and Actiq are contraindicated in the management of acute or postoperative pain, and for use in opioid non-tolerant patients. A unique adverse event issue identified with use of Fentora is application site reactions, including ulceration. Risk is difficult to define, due to the limited number of patients and duration of exposure to this formulation in clinical trials. This side effect has the potential to alter the formulation s absorption characteristics and may Page 7 of 11

8 increase risk for serious side effects in some patients. To ensure safety, a cautious approach to use of either transmucosal fentanyl product is warranted. Management of chronic severe pain in cancer patients requires the effective use of long-acting opioids, supplemented with limited doses of a short-acting opioid (rescue medication). Excessive doses of rescue medication usually indicate suboptimal pain control. This problem can be alleviated by increasing the fraction of the total daily opioid dose given as long-acting opioid Update A literature search from January 2012 through October 2012 did not indicate need to update the criteria in this policy Update Updated with new FDA labeling and stricter FDA indication wording. In 2013, the FDA acted to increased opioid abuse and death by narrowing labeled indications to only severe, around-theclock pain for which other treatments are inadequate, added post-marketing surveillance requirements on manufacturers, and a block box warning Update Additional criteria for transmucosal fentanyl products added. Criteria for review of Zohydro (hydrocodone ER) added. The proliferation and increasing use of transmucosal fentanyl products for the treatment of breakthrough pain is causing considerable concern. Furthermore, the studies supporting these products are company-sponsored, raising concern for potential bias, and appropriate head-to-head comparisons have not been performed. Measurement of endpoints varies across studies; further confounding attempts to evaluate these agents as a class. Time of onset is usually measured by when there is a statistically significant difference in pain scores, which does not necessarily equate to a clinically meaningful difference. The pharmacokinetics of fentanyl make is an easily abusable opioid. None of these products are indicated for pediatric use, nor do any of them have randomized controlled trials in pediatric patients. In their recent review of managing breakthrough pain in pediatric patients, Friedrichsdorf and Postier do not recommend their use in pediatric patients. Page 8 of 11

9 Zohydro ER is a non-tamper resistant formulation of hydrocodone without acetaminophen. Although FDA approved this product, it has not been launched at this time, and concerns are rising about the abuse potential of this substance, which studies have shown to be among the preferred prescription opioids of abuse in the U.S. Recently, a bipartisan bill was introduced in Congress to prohibit the distribution of non-tamper-resistant forms Update Quantity limit criteria for transmucosal fentanyl products (TIRFs) has been removed. References 1. Silverstein FE, Faich G, Goldstein JL et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: The CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA 2000; 284: Bombardier C, Laine L, Reicin A et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. (VIGOR) NEJM 2000; 343: Lai KC, Chu KM, Hui WM, et al. Celecoxib compared with lansoprazole and naproxen to prevent gastrointestinal ulcer complications. Am J Med Nov;118(11): Chan FK, Hung LC, Suen BY, et al. Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. NEJM Dec 26;347(26): Celecoxib plus aspirin versus naproxen and lansoprazole plus aspirin: a randomized, double-blind, endoscopic trial. Clin Gastroenterol Hepatol Oct;5(10): Coluzzi PH, Schwartzberg L, Conroy JD et al. Breakthrough cancer pain: a randomized trail comparing oral transmucosal fentanyl citrate (OFTC ) and morphine sulfate immediate release (MSIR ). Pain. 2001;91: Payne R, Coluzzi P, Hart L et al. Long-term safety of oral transmucosal fentanyl citrate for breakthrough cancer pain. J Pain Symptom Manage. 2001;22: Farrar JT, Cleary J, Rauck R et al. Oral transmucosal fentanyl citrate: randomized, double-blind, placebo controlled trial for treatment of breakthrough pain in cancer patients. J Natl Cancer Inst. 1998;90: SAMHSA. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2007b. 10. US Department of Health and Human Services, substance abuse and mental health services administration. Results from the 2007 national survey on drug use and health: national findings. NSDUH Series H-34, DSHS Publication No. SMA Rockville, MD: Office of Applied Studies, Webster, L. Update on Abuse-resistant and abuse-deterrent approaches to opioid formulations. Pain Med 2009;10 Suppl 2:S124-S133. Page 9 of 11

10 12. Drug Abuse Warning Network (DAWN): Drug-related emergency department visits for [online]. Available online: Accessed May Moore TJ, Cohen MR and Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, Arch Intern Med 2007;167 (16): Coolen P, Best S, Lima A, et al. Overdose deaths involving prescription opioids among Medicaid enrollees Washington, MMWR 2009;58(42): US Department of Health and Human Services, Substance Abuse and Mental Health Services. Summary report of the meeting: methadone mortality a reassessment [online]. Available online: Mortality/BKD498 Accessed May Walsh SL, Nuzzo PA, Lofwall MR and Holtman JR. The relative abuse liability of oral oxycodone, hydrocodone, and hydromorphone assessed in prescription opioid abusers. Drug Alcohol Depend 2008;98(3): Twycross R, Prommer E, Mihalyo M, Wilcock A. Fentanyl (transmucosal). J Pain Symptom Management 2012;44(1): Nalamachu S, Rauck R, Dilaha L, Parikh N. Lack of correlation between the dose of fentanyl sublingual spray for breakthrough cancer pain and the dose of around-the-clock opioid for persistent pain. J Pain 2013;14:S Zeppetella G, Davies AN. Opioids for the management of breakthrough pain in cancer patients. Cochrane Database Syst Rev 2013; Oct 21;10:CD doi: / CD pub Friedrichsdorf SJ, Postier A. Management of breakthrough pain in children with cancer. J Pain Research 2014;7: Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm Rep 2016; 65:1 49. DOI: Accessed May History Date Comments 02/08/11 Add to Prescription Drug Section - New Policy. 12/13/11 Replace Policy Policy updated with additional approval parameters and dosing limitation for OxyContin. 11/13/12 Replace policy. A literature search did not indicate the need to update the criteria in this policy. 03/15/13 Update Related Policies. Add /08/13 Minor Update Clarification was added to the policy that it is managed through the member s pharmacy benefit; this is now listed in the header and within the coding section. 10/14/13 Replace policy. Medically necessary policy statement for OxyContin updated with new FDA labeling and stricter FDA indication wording. 04/14/14 Annual review. Policy updated with extended-release hydrocodone (Zohydro ER ) as medically necessary for the labeled indication of the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which Page 10 of 11

11 Date Comments alternative treatment options are inadequate. 12/01/14 Update Related Policies. Add /13/15 Annual Review. Policy statements for Cox-II (Celebrex) removed as this medication no longer requires prior authorization. Title updated, removed Non-Opiod as this only pertained to Celebrex. 02/09/16 Annual Review. Criteria for Zohydro ER removed from Policy Guidelines: concomitant therapy with CNS depressants or inhibitors of CYP3A4; no history of COPD; and, no current or recent head injury. 05/01/16 Interim update, approved April 12, Additional criteria for OxyContin and Zohydro ER quantity limit are included. 01/01/17 Interim Update, approved December 13, Quantity limit criteria for transmucosal fentanyl products (TIRFs) has been removed. 06/01/17 Annual Review, approved May 23, Policy moved into new format. Created introduction summary and removed the word preferred from the coverage criteria for Zohydro ER. Medical records requirement statement is now included in the policy. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Page 11 of 11

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Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama ( )

13 日本語 (Japanese): この通知には重要な情報が含まれています この通知には Premera Blue Cross の申請または補償範囲に関する重要な情報が含まれている場合があります この通知に記載されている可能性がある重要な日付をご確認ください 健康保険や有料サポートを維持するには 特定の期日までに行動を取らなければならない場合があります ご希望の言語による情報とサポートが無料で提供されます (TTY: ) までお電話ください 한국어 (Korean): 본통지서에는중요한정보가들어있습니다. 즉이통지서는귀하의신청에관하여그리고 Premera Blue Cross 를통한커버리지에관한정보를포함하고있을수있습니다. 본통지서에는핵심이되는날짜들이있을수있습니다. 귀하는귀하의건강커버리지를계속유지하거나비용을절감하기위해서일정한마감일까지조치를취해야할필요가있을수있습니다. 귀하는이러한정보와도움을귀하의언어로비용부담없이얻을수있는권리가있습니다 (TTY: ) 로전화하십시오. ລາວ (Lao): ແຈ ງການນ ມ ຂ ມ ນສ າຄ ນ. ແຈ ງການນ ອາດຈະມ ຂ ມ ນສ າຄ ນກ ຽວກ ບຄ າຮ ອງສະ ໝ ກ ຫ ຄວາມຄ ມຄອງປະກ ນໄພຂອງທ ານຜ ານ Premera Blue Cross. ອາດຈະມ ວ ນທ ສ າຄ ນໃນແຈ ງການນ. ທ ານອາດຈະຈ າເປ ນຕ ອງດ າເນ ນການຕາມກ ານ ດ ເວລາສະເພາະເພ ອຮ ກສາຄວາມຄ ມຄອງປະກ ນສ ຂະພາບ ຫ ຄວາມຊ ວຍເຫ ອເລ ອງ ຄ າໃຊ ຈ າຍຂອງທ ານໄວ. ທ ານມ ສ ດໄດ ຮ ບຂ ມ ນນ ແລະ ຄວາມຊ ວຍເຫ ອເປ ນພາສາ ຂອງທ ານໂດຍບ ເສຍຄ າ. ໃຫ ໂທຫາ ភ ស ខមរ (Khmer): សចកត ជ នដ ណ ង ន ម នព ត ម នយ ងស ខ ន សចកត ជ នដ ណ ង ន រប ហល ជ ម នព ត ម នយ ងស ខ ន អ ព ទរមង បបបទ ឬក ររ ប រងរបស អនកត មរយ Premera Blue Cross រប ហលជ ម ន ក លបរ ចឆទស ខ ន ន កន ង សចកត ជ ន ដ ណ ង ន អនករប ហលជ រត វក រប ញច ញសមតថភ ព ដល ក ណត ថងជ ក ចប ស ន ន ដ មប ន ងរកស ទ កក រធ ន រ ប រងស ខភ ពរបស អនក ឬរប ក ជ ន យ ចញ ថល អនកម នស ទធ ទទ លព ត ម ន ន ន ងជ ន យ ន កន ងភ ស របស អនក ដ យម នអស ល យ ឡ យ ស មទ រស ពទ (TTY: ) ਪ ਜ ਬ (Punjabi): ਇਸ ਨ ਟਸ ਵਚ ਖ ਸ ਜ ਣਕ ਰ ਹ. ਇਸ ਨ ਟਸ ਵਚ Premera Blue Cross ਵਲ ਤ ਹ ਡ ਕਵਰ ਜ ਅਤ ਅਰਜ ਬ ਰ ਮਹ ਤਵਪ ਰਨ ਜ ਣਕ ਰ ਹ ਸਕਦ ਹ. ਇਸ ਨ ਜਸ ਜਵਚ ਖ ਸ ਤ ਰ ਖ ਹ ਸਕਦ ਆ ਹਨ. ਜ ਕਰ ਤ ਸ ਜਸਹਤ ਕਵਰ ਜ ਰ ਖਣ ਹ ਵ ਜ ਓਸ ਦ ਲ ਗਤ ਜ ਵ ਚ ਮਦਦ ਦ ਇਛ ਕ ਹ ਤ ਤ ਹ ਨ ਅ ਤਮ ਤ ਰ ਖ਼ ਤ ਪ ਹਲ ਕ ਝ ਖ ਸ ਕਦਮ ਚ ਕਣ ਦ ਲ ੜ ਹ ਸਕਦ ਹ,ਤ ਹ ਨ ਮ ਫ਼ਤ ਵ ਚ ਤ ਆਪਣ ਭ ਸ਼ ਵ ਚ ਜ ਣਕ ਰ ਅਤ ਮਦਦ ਪ ਰ ਪਤ ਕਰਨ ਦ ਅ ਧਕ ਰ ਹ,ਕ ਲ (Farsi): فارسی اين اعالميه حاوی اطالعات مھم ميباشد.اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم تقاضا و يا پوشش بيمه ای شما از طريق Premera Blue Cross باشد. به تاريخ ھای مھم در اين اعالميه توجه نماييد.شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه ھای درمانی تان به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد.شما حق اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد. برای کسب اطالعات با شماره (کاربران TTY تماس باشماره ) تماس برقرار نماييد. Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону Fa asamoa (Samoan): Atonu ua iai i lenei fa asilasilaga ni fa amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa asilasilaga o se fesoasoani e fa amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa amolemole, ia e iloilo fa alelei i aso fa apitoa olo o iai i lenei fa asilasilaga taua. Masalo o le a iai ni feau e tatau ona e faia ao le i aulia le aso ua ta ua i lenei fa asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo o e iai i ai. Olo o iai iate oe le aia tatau e maua atu i lenei fa asilasilaga ma lenei fa matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa ไทย (Thai): ประกาศน ม ข อม ลส าค ญ ประกาศน อาจม ข อม ลท ส าค ญเก ยวก บการการสม ครหร อขอบเขตประก น ส ขภาพของค ณผ าน Premera Blue Cross และอาจม ก าหนดการในประกาศน ค ณอาจจะต อง ด าเน นการภายในก าหนดระยะเวลาท แน นอนเพ อจะร กษาการประก นส ขภาพของค ณหร อการช วยเหล อท ม ค าใช จ าย ค ณม ส ทธ ท จะได ร บข อม ลและความช วยเหล อน ในภาษาของค ณโดยไม ม ค าใช จ าย โทร (TTY: ) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số