MEDICAL POLICY 7.03.12 Islet Transplantation BCBSA Ref. Policy: 7.03.12 Effective Date: Oct. 1, 2017 Last Revised: Sept. 21, 2017 Replaces: N/A RELATED MEDICAL POLICIES: None 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 The pancreas is an organ that stretches lengthwise across the abdominal area below the stomach. Within the pancreas are cell clusters commonly called the islets. Included in the islets are beta cells which make, store, and release insulin. Treating chronic inflammation of the pancreas may mean removing the pancreas. Removing the pancreas also removes the islets and the beta cells, which then leads to type 1 diabetes. To prevent the development of type 1 diabetes in people who have their pancreas removed, their own islet cells can be harvested and injected into a specific vein in the liver. Published medical studies show that islet cell transplantation appears to significantly decrease the development diabetes after the pancreas is removed. In this situation, islet cell transplantation may be considered medically necessary. Islet cell transplantation using donor cells is being studied as a technique to treat existing type 1 diabetes. There is not enough medical evidence to show how well this works to treat type 1 diabetes. Larger and longer studies are needed. For these reasons, islet cell transplantation to treat existing type 1 diabetes is investigational (unproven). 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 Procedure Autologous pancreas islet transplantation Medical Necessity Autologous pancreas islet transplantation may be considered medically necessary as an adjunct to a total or near total pancreatectomy in patients with chronic pancreatitis. Procedure Allogeneic islet transplantation Islet transplantation, all other Investigational Allogeneic islet transplantation is considered investigational for the treatment of type 1 diabetes. Islet transplantation is considered investigational in all other situations. Coding Code Description CPT 48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells HCPCS G0341 G0342 G0343 S2102 Note: Percutaneous islet cell transplant, includes portal vein catheterization and infusion Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion Laparotomy for islet cell transplant, includes portal vein catheterization and infusion Islet cell tissue transplant from pancreas; allogeneic CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS). Related Information Page 2 of 9
Benefit Application Islet transplantation is a specialized procedure that may require referral to an out-of-network facility. Evidence Review Description Performed in conjunction with pancreatectomy, autologous islet transplantation is proposed to prevent the development of insulin-dependent diabetes. Moreover, allogeneic islet transplantation is being investigated as a treatment or cure for patients who already have type 1 diabetes. Background Islet Transplantation When an autologous islet transplantation is done during a pancreatectomy, cells from the islets are isolated from the resected pancreas using enzymes, and a suspension of the cells is injected into the portal vein of the patient s liver. Once implanted, the beta cells in these islets begin to make and release insulin. In the case of allogeneic islet transplantation, cells are harvested from the deceased donor s pancreas, processed, and injected into the recipient s portal vein. Up to 3 donor pancreas transplants may be required to achieve insulin independence. Allogeneic transplantation may be performed in the radiology department. Chronic Pancreatitis Primary risk factors for chronic pancreatitis are included in the TIGAR-O classification system (Toxic-metabolic factors [eg, alcohol, smoking], Idiopathic, Genetic, Autoimmune, Recurrent and severe acute pancreatitis, or Obstructive conditions). Patients with chronic pancreatitis may experience intractable pain that can only be relieved with a total or near total pancreatectomy. Page 3 of 9
However, the pain relief must be balanced against the certainty that the patient will become an insulin-dependent diabetic. Type 1 Diabetes Allogeneic islet transplantation has been used for type 1 diabetes to restore normoglycemia and, ultimately, to reduce or eliminate the long-term complications of diabetes such as retinopathy, neuropathy, nephropathy, and cardiovascular disease. Islet transplantation potentially offers an alternative to whole-organ pancreas transplantation. However, a limitation of islet transplantation is that 2 or more donor organs are usually required for successful transplantation, although experimentation with single-donor transplantation is occurring. A pancreas that is rejected for whole-organ transplant is typically used for islet transplantation. Therefore, islet transplantation has generally been reserved for patients with frequent and severe metabolic complications who have consistently failed to achieve control with insulinbased management. In 2000, a modified immunosuppression regimen increased the success of allogeneic islet transplantation. This regimen was developed in Edmonton, AB, Canada, and is known as the Edmonton protocol. Summary of Evidence For individuals with chronic pancreatitis undergoing total or near total pancreatectomy who receive autologous pancreas islet transplantation, the evidence includes case series and systematic reviews. Relevant outcomes are overall survival, change in disease status, medication use, resource utilization, and treatment-related morbidity. Autologous islet transplants are performed in the context of total or near total pancreatectomies to treat intractable pain for chronic pancreatitis. The procedure appears to significantly decrease the incidence of diabetes after total or near total pancreatectomy in patients with chronic pancreatitis. Also, this procedure itself is not associated with serious complications and is performed in patients who are already undergoing a pancreatectomy procedure. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals with type 1 diabetes who receive allogeneic pancreas islet transplantation, the evidence includes case series and systematic reviews. Relevant outcomes are overall survival, change in disease status, medication use, resource utilization, and treatment-related morbidity. A wide range of insulin independence has been reported in case series. There is conflicting Page 4 of 9
evidence whether allogeneic islet transplantation reduces long-term diabetic complications. Long-term comparative studies are required to determine the effects of allogeneic islet transplantation in type 1 diabetics. The evidence is insufficient to determine the effects of the technology on health outcomes. Ongoing and Unpublished Clinical Trials Some currently unpublished trials that might influence this review are listed in Table 1. Table 1. Summary of Key Trials NCT No. Trial Name Planned Completion Enrollment Date Ongoing NCT00679042 Islet Transplantation in Type 1 Diabetic Patients Using the 1000 Sep 2017 University of Illinois at Chicago (UIC) Protocol NCT00706420 Islet Transplantation Alone (ITA) in Patients With Difficult to Control Type I Diabetes Mellitus Using a Glucocorticoid-free Immunosuppressive Regimen 20 May 2018 NCT02505893 Minimal Islet Transplant at Diabetes Onset (MITO) 6 May 2018 NCT00160732 Allogenic Islet Cell Transplantation 50 Oct 2018 NCT01897688 A Phase 3 Single Center Study of Islet Transplantation in Non-uremic Diabetic Patients 20 Dec 2018 NCT00306098 Islet Cell Transplantation Alone in Patients With Type 1 Diabetes Mellitus: Steroid-Free Immunosuppression 40 May 2019 NCT01909245 Islet Cell Transplant for Type 1 Diabetes (TCD) 30 Jul 2021 NCT01974674 Allogeneic Islet Transplantation for the Treatment of Type 1 Diabetes (GRIIF) 19 Jan 2022 NCT: national clinical trial. Practice Guidelines and Position Statements Guidance from the National Institute for Care Excellence, published in 2008, indicated the evidence on allogeneic pancreatic islet cell transplantation for type 1 diabetes has shown that Page 5 of 9
serious complications may occur, and the long-term immunosuppression required is associated with the risk of adverse events. 15 A related 2008 guidance that addressed autologous islet cell transplantation for improved glycemic control after pancreatectomy stated that studies have shown some short-term efficacy, although most patients require insulin therapy in the long term. Complications mainly result from the major surgery involved in pancreatectomy rather than from the islet cell transplantation. 16 Medicare National Coverage Effective October 1, 2004, Medicare will cover pancreatic islet transplantation in patients with type 1 diabetes participating in the context of a clinical trial sponsored by the National Institutes of Health. 17 Partial pancreatic tissue transplantation or islet transplantation performed outside the context of a clinical trial will continue to not be covered. Regulatory Status The U.S. Food and Drug Administration regulates human cells and tissues intended for implantation, transplantation, or infusion through the Center for Biologics Evaluation and Research, under Code of Federal Regulation title 21, parts 1270 and 1271. Allogeneic islet cells are included in these regulations. References 1. Wu Q, Zhang M, Qin Y, et al. Systematic review and meta-analysis of islet autotransplantation after total pancreatectomy in chronic pancreatitis patients. Endocr J. Mar 30 2015;62(3):227-234. PMID 25735805 2. Dong M, Parsaik AK, Erwin PJ, et al. Systematic review and meta-analysis: islet autotransplantation after pancreatectomy for minimizing diabetes. Clin Endocrinol (Oxf). Dec 2011;75(6):771-779. PMID 21605156 3. Wilson GC, Sutton JM, Abbott DE, et al. Long-term outcomes after total pancreatectomy and islet cell autotransplantation: is it a durable operation? Ann Surg. Oct 2014;260(4):659-665; discussion 665-657. PMID 25203883 4. Chinnakotla S, Radosevich DM, Dunn TB, et al. Long-term outcomes of total pancreatectomy and islet auto transplantation for hereditary/genetic pancreatitis. J Am Coll Surg. Apr 2014;218(4):530-543. PMID 24655839 5. Sutherland DE, Radosevich DM, Bellin MD, et al. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. J Am Coll Surg. Apr 2012;214(4):409-424. PMID 22397977 Page 6 of 9
6. Food and Drug Administration (FDA). Guidance for Industry: Considerations for Allogeneic Pancreatic Islet Cell Prodcuts. 2009; http://www.fda.gov/downloads/biologicsbloodvaccines/guidancecomplianceregulatoryinformation/guidances/cellul arandgenetherapy/ucm182441.pdf Accessed September 2017. 7. Piper M, Seidenfeld J, Aronson N. Islet transplantation in patients with type 1 diabetes mellitus. Evid Rep Technol Assess (Summ). Jul 2004(98):1-6. PMID 15366369 8. Alejandro R, Barton FB, Hering BJ, et al. 2008 Update from the Collaborative Islet Transplant Registry. Transplantation. Dec 27 2008;86(12):1783-1788. PMID 19104422 9. Barton FB, Rickels MR, Alejandro R, et al. Improvement in outcomes of clinical islet transplantation: 1999-2010. Diabetes Care. Jul 2012;35(7):1436-1445. PMID 22723582 10. Thompson DM, Meloche M, Ao Z, et al. Reduced progression of diabetic microvascular complications with islet cell transplantation compared with intensive medical therapy. Transplantation. Feb 15 2011;91(3):373-378. PMID 21258272 11. Caiazzo R, Vantyghem MC, Raverdi V, et al. Impact of procedure-related complications on long-term islet transplantation outcome. Transplantation. May 2015;99(5):979-984. PMID 25393157 12. O'Connell PJ, Holmes-Walker DJ, Goodman D, et al. Multicenter Australian trial of islet transplantation: improving accessibility and outcomes. Am J Transplant. Jul 2013;13(7):1850-1858. PMID 23668890 13. Rickels MR, Kong SM, Fuller C, et al. Improvement in insulin sensitivity after human islet transplantation for type 1 diabetes. J Clin Endocrinol Metab. Nov 2013;98(11):E1780-1785. PMID 24085506 14. Health Quality Ontario. Pancreas islet transplantation for patients with type 1 diabetes mellitus: a clinical evidence review. Ont Health Technol Assess Ser. 2015;15(16):1-84. PMID 26644812 15. National Institute for Health and Care Excellence (NICE). Allogenic pancreatic islet cell transplantation for type 1 diabetes mellitus [IPG257]. 2008; http://www.nice.org.uk/guidance/ipg257 Accessed September 2017. 16. National Institute for Health and Care Excellence (NICE). Autologous pancreatic islet cell transplantation for improved glycaemic control after pancreatectomy [IPG274]. 2008; http://www.nice.org.uk/guidance/ipg274 Accessed September 2017. 17. Centers for Medicare and Medicaid. National Coverage Determination (NCD) for ISLET CELL Transplantation in the Context of a Clinical Trial (260.3.1). 2004; https://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?ncdid=286&ncdver=1&coverageselection=both&articletype=all&policytype=final&s=all&keyword=i slet+cell&keywordlookup=title&keywordsearchtype=and&bc=gaaaabaaaaaa& Accessed September 2017. History Date Comments 11/13/01 Add to Surgery Section - New Policy 03/08/05 Replace Policy - Policy reviewed; added information on islet transplantation for type I diabetes and statement that this indication is considered investigational; added Medicare coverage policy information on islet transplantation for type 1 diabetes; removed autologous from the policy title; HCPCS codes updated. 12/13/05 Replace Policy - Policy reviewed with literature search; reference added. Policy statement and title updated with removal of cell when describing islet transplantation rather than islet cell transplantation. Page 7 of 9
Date Comments 05/26/06 Scope and Disclaimer Updates - No other changes. 09/12/06 Replace Policy - Policy updated with literature search; no change to policy statement; reference added. 03/11/08 Replace Policy - Policy updated with literature search; no change to policy statement; reference added. 07/14/09 Replace Policy - Policy updated with literature search; no change to policy statement. Benefit Application section updated. References added. 09/14/10 Replace Policy - Policy updated with literature review; rationale section extensively edited. References numbers 16 18 have been added; the policy statements remain unchanged. 08/09/11 Replace Policy Policy updated with literature review. Reference numbers 13 and 17 added; other references renumbered or removed; policy statements unchanged. ICD- 10 codes added to policy. 08/20/12 Replace Policy. Rationale section revised based on literature review through April 2012. References 1-3 and 14 added, other references renumbered or removed. Policy statements unchanged. 09/28/12 Update Coding Section ICD-10 codes are now effective 10/01/2014. 01/10/13 Coding update. CPT codes 0141T 0143T removed from policy; they were deleted as of 1/1/12. 08/16/13 Replace policy. Policy guidelines reformatted for readability. Rationale updated with literature review through April 18, 2013. Ongoing clinical trial added. Reference numbers 7,9,11 and 16 added; others renumbered or removed. Policy statements unchanged. 03/11/14 Coding Update. Codes 52.85 and 52.86 were removed per ICD-10 mapping project; these codes are not utilized for adjudication of policy. 07/31/14 Annual Review. Policy updated with literature review through March 26, 2014. Reference numbers 4, 10, 11 and 20 added. Statement added that islet transplantation is considered investigational in all other situations. 07/14/15 Annual Review. Policy updated with literature review through April 8, 2015; references 1, 3, 6, and 11 added. Policy statements unchanged. ICD-9 and ICD-10 procedure codes removed; these were listed for informational purposes only. 12/01/16 Annual Review, approved November 8, 2016. Policy updated with literature review through October 10, 2016; reference 17 added. Policy statements unchanged. 10/01/17 Annual Review, approved September 21, 2017. Policy updated with literature review through June 22, 2017; clinical trials section added; reference 14 added; reference 17 updated. Removed CPT code 48999. Policy statements unchanged. Page 8 of 9
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). 2017 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 9 of 9
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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 800-722-1471 (TTY: 800-842-5357) までお電話ください 한국어 (Korean): 본통지서에는중요한정보가들어있습니다. 즉이통지서는귀하의신청에관하여그리고 Premera Blue Cross 를통한커버리지에관한정보를포함하고있을수있습니다. 본통지서에는핵심이되는날짜들이있을수있습니다. 귀하는귀하의건강커버리지를계속유지하거나비용을절감하기위해서일정한마감일까지조치를취해야할필요가있을수있습니다. 귀하는이러한정보와도움을귀하의언어로비용부담없이얻을수있는권리가있습니다. 800-722-1471 (TTY: 800-842-5357) 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 800-722-1471 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 800-722-1471 (TTY: 800-842-5357) 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 800-722-1471 (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 800-722-1471 (کاربران TTY تماس باشماره 800-842-5357) 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 800-722-1471 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 800-722-1471 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 800-722-1471 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 800-722-1471 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 800-722-1471 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 800-722-1471 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 800-722-1471 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 800-722-1471 (TTY: 800-842-5357) 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 800-722-1471 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 800-722-1471