MEDICAL POLICY – 7.01.580 Prophylactic Bilateral Salpingo-

Ref. Policy: MP-076 Effective Date: Oct. 1, 2021 RELATED MEDICAL POLICIES: Last Revised: Sept. 23, 2021 10.01.526 Molecular Genetic Testing: Services Reviewed by AIM® Replaces: N/A

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Introduction

Prophylactic bilateral salpingo-oophorectomy is surgery that removes both . The goal of this surgery is to reduce the risk of ovarian, , peritoneal, and breast cancers, particularly for those women who are at high risk. This policy describes when prophylactic bilateral salpingo-oophorectomy may be considered medically necessary.

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

Service Medical Necessity Prophylactic bilateral Prophylactic bilateral salpingo-oophorectomy (PBSO) may be salpingo-oophorectomy considered medically necessary for the following indications: (PBSO) Service Medical Necessity • PBSO is considered medically necessary for select individuals at high-risk of inherited ovarian cancer when the patient meets one of the following: o The patient has a positive BRCA1 or BRCA 2 genetic test (refer to 10.01.526 Molecular Genetic Testing: Services Reviewed by AIM®) or has been diagnosed with a hereditary ovarian cancer syndrome based on a family pedigree constructed by a provider competent to determine the presence of an autosomal dominant inheritance pattern OR o There are two first degree relatives (ie, parent, sibling or child of the individual) with a history of epithelial ovarian cancer or breast cancer OR o There is one first degree relative and one or more second degree relatives with epithelial ovarian cancer OR o The patient has a personal history of breast cancer and at least one first degree relative with epithelial ovarian cancer OR o There are two or more second degree relatives with history of ovarian cancer or breast cancer OR o The patient has a personal history of estrogen receptor positive, premenopausal breast cancer • PBSO shall be considered for coverage in hereditary nonpolyposis colorectal cancer (HNPCC) when a prophylactic is performed in these cases

The decision to perform PBSO should not be based only on age; it should be a highly individualized decision that takes into account several patient factors and choices. Hormone replacement therapy could be considered for women undergoing PBSO and patients should be counseled about the risks and benefits of hormone replacement therapy prior to undergoing surgery.

Page | 2 of 7 ∞ Service Medical Necessity

For women with BRCA1 or mutations, risk-reducing PBSO should be offered after the completion of childbearing and only deferred beyond the early 40s following a careful discussion of the risks and benefits.

In individuals with a personal or family history suggestive of an inherited predisposition to breast and ovarian cancer who have not had genetic testing or who have undergone genetic testing and have not had a deleterious BRCA1 or BRCA2 mutation identified, less information is available regarding the relative risks and benefits of PBSO. These individuals are best managed by a multidisciplinary team of gynecologists, gynecologic oncologists, and geneticists experienced in the care of women at inherited risk for cancer.

Note: See Related Information below for Limitations

Coding

Code Description CPT 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)

58940 Oophorectomy, partial or total, unilateral or bilateral;

ICD-10 Codes Covered if Selection Criteria are Met C56.1-C56.9 Malignant neoplasm of

C57.00-C57.02 Malignant neoplasm of fallopian tube

C57.10-C57.12 Malignant neoplasm of broad ligament

C57.20-C57.22 Malignant neoplasm of round ligament

C57.3 Malignant neoplasm of parametrium

Page | 3 of 7 ∞ Code Description C57.4 Malignant neoplasm of uterine adnexa, unspecified

C57.7-C57.9 Malignant neoplasm of other specified female genital organs, overlapping sites of female genital organs, and female genital organs unspecified

C79.60-C79.62 Secondary malignant neoplasm of ovary

D27.0-D27.9 Benign neoplasm of ovary

D39.10-D39.12 Neoplasm of uncertain behavior or unspecified ovary

N83.0-N83.9 Non-inflammatory disorders of ovary, fallopian tube, and broad ligament

N94.89 Other specified conditions associated with female genital organs and menstrual cycle

O00.0-O00.9 and other ectopic pregnancy

P01.4 Newborn (suspected to be) affected by ectopic pregnancy

Z40.00 Encounter for prophylactic removal of unspecified organ

Z40.02 Encounter for prophylactic removal of ovary

Z40.09 Encounter for prophylactic removal of other organ

Note: 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

Definition of Terms

Breast cancer: Invasive breast cancer or ductal carcinoma in situ

First-degree relative: Parent, sibling or child of an individual

Ovarian cancer: Epithelial ovarian cancer

Second-degree relative: Grandparent, aunt, uncle, half-sibling, niece, nephew or grandchild of an individual

Third-degree relative: Great-grandparent, great-uncle, great-aunt, first cousin, grand-niece, grand-nephew, or great-grandchild of an individual

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Limitations

• Genetic testing of a non-covered family member of the patient for the sole purpose of obtaining non-related genetic information is not covered.

• Occasionally, blood or tissue samples from other non-covered family members are required to provide the medical information necessary for the proper medical care of a patient. Molecular-based testing for BRCA and other specific heritable disorders in non-members is covered when all of the following conditions are met:

o The information is needed to adequately assess risk in the patient.

AND

o The information will be used in the immediate care plan of the patient.

AND

o The non-covered family member's benefit plan (if any) will not cover the test and the denial is based on specific plan exclusion.

Evidence Review

Background

Prophylactic bilateral oophorectomy is a surgical procedure that removes both ovaries. The goal of this surgery is to reduce the risk of ovarian, fallopian tube, and peritoneal cancers, particularly for those women who are at high risk. This procedure can be done at the same time as the removal of the fallopian tubes during a hysterectomy. Risk factors can include family history of breast or ovarian cancer and/or the presence of mutations in the BRCA1/2 gene.

Approximately 5-10% of all inherited cases of breast and ovarian cancers are associated with mutations in the BRCA1/2 genes. According to the American College of Obstetricians and Gynecologists (ACOG), ovarian cancer has the highest mortality rate out of all types of gynecologic cancer and is the 5th leading cause of cancer deaths among women.

Page | 5 of 7 ∞ References

1. American College of Obstetricians and Gynecologists (ACOG). Committee on Gynecologic Practice: Committee Opinion: The Role of the Obstetrician-Gynecologist in the Early Detection of Epithelial Ovarian Cancer. No. 716, September 2017. Re-affirmed 2019 https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/09/the-role-of-the- obstetriciangynecologist-in-the-early-detection-of-epithelial-ovarian-cancer-in-women-at-average-risk Accessed September 9, 2021

2. American College of Obstetricians and Gynecologists (ACOG). Committee on Gynecologic Practice. Committee Opinion: Salpingectomy for Ovarian Cancer Prevention. No. 774, April 2019. https://www.acog.org/clinical/clinical- guidance/committee-opinion/articles/2019/04/opportunistic-salpingectomy-as-a-strategy-for-epithelial-ovarian- cancer-prevention Accessed September 9, 2021

3. Nurse Practitioners in Women’s Health. Position Statement on Hereditary Breast and Ovarian Cancer Risk Assessment. April 2017. https://www.npwh.org/lms/filebrowser/file?fileName=NPWH%20HBOC%20Position%20Statement%20BOD%20approv ed%204.17%20(2).pdf Accessed September 9, 2021

4. Domchek SM, Friebel TM, Singer CF, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA 2010 Sep 1;304(9):967-75. doi: 10.1001/jama.2010.1237. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948529/pdf/ukmss-31697.pdf Accessed September 9, 2021

5. Rebbeck TR, Kauff NK, Domchek SM. Meta-analysis of risk reduction estimates associated with risk-reducing salpingo- oophorectomy in BRCA1 or BRCA 2 mutation carriers. J Natl Cancer Inst. 2009 Jan; 101(2): 80-87. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639318/pdf/djn442.pdf Accessed September 9, 2021

6. Schmeler KM, Sun CC, Bodurka DC, et al. : Prophylactic bilateral Salpingo-Oophorectomy compared with surveillance in women with BRCA mutations. Obstet Gynegol. 2006 Sep;108(3 Pt 1):515-520. http://www.ncbi.nlm.nih.gov/pubmed/16946209 Accessed September 9, 2021

7. Society of Gynecologic Oncologists Clinical Practice Committee Statement on Prophylactic Salpingo-Oophorectomy. Gynecol Oncol. 2005; 98(2): 179-181. http://www.download.thelancet.com/journals/lanonc/article/PIIS1470-2045(06)70589- 7/fulltext Accessed September 9, 2021

8. U.S. Preventive Services Task Force. Final Recommendation Statement: BRCA-related Cancer: Risk Assessment, Genetic Counseling and Genetic Testing, August 20,2019 http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer- risk-assessment-genetic-counseling-and-genetic-testing Accessed September 9, 2021

9. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer: Systematic Review to Update the U.S. Preventive Services Task Force Recommendation https://www.ncbi.nlm.nih.gov/books/NBK179204/ Accessed September 9, 2021

10. NCI Dictionary of Genetics Terms https://www.cancer.gov/publications/dictionaries/genetics-dictionary?cdrid=460150 Accessed September 9, 2021

11. Definitions specific to the Genetic Information Nondiscrimination Act of 2008 [29 CFR 1635.3] https://www.gpo.gov/fdsys/pkg/CFR-2011-title29-vol4/xml/CFR-2011-title29-vol4-part1635.xml Accessed September 9, 2021.

History

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Date Comments 09/16/19 New policy, approved August 13, 2019, effective January 1, 2020. Prophylactic bilateral salpingo-oophorectomy (PBSO) may be considered medically necessary for patients at high-risk or with hereditary nonpolyposis colorectal cancer (HNPCC) when criteria are met.

10/01/20 Annual Review, approved September 17, 2020. No changes to policy statement, references updated.

10/01/21 Annual Review, approved September 23, 2021. No changes to policy statement, references updated.

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). ©2021 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 only applies to Individual Plans.

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ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ። Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti Arabic): partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti) العربية salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti يحوي ھذا اإلشعار معلومات ھامة . قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti التغطية التي تريد الحصول عليھا من خالل Premera Blue Cross. قد تكون ھناك تواريخ مھمة .(bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357 في ھذا اإلشعار . وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع التكاليف . يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة . اتصل :(Italiano (Italian بـ(TTY: 800-842-5357) 800-722-1471 Questo avviso contiene informazioni importanti. Questo avviso può contenere 中文 (Chinese): informazioni importanti sulla tua domanda o copertura attraverso Premera 本通知有重要的訊息。 本通知可能有關於您透過 Premera Blue Cross 提交的 Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe 申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期 essere necessario un tuo intervento entro una scadenza determinata per 之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母 consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. 語得到本訊息和幫助。請撥電話 。 800-722-1471 (TTY: 800-842-5357) Chiama 800-722-1471 (TTY: 800-842-5357).

037338 (07-2016) 日本語 (Japanese): Română (Romanian): 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 Prezenta notificare conține informații importante. Această notificare 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 poate conține informații importante privind cererea sau acoperirea asigurării 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 dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în aceast notificare. Este posibil s fie nevoie s ac iona i pân la anumite 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 ă ă ă ț ț ă termene limită pentru a vă menține acoperirea asigurării de sănătate sau 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 asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話 informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 ください。 (TTY: 800-842-5357).

한국어 (Korean): Pусский (Russian): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 Настоящее уведомление содержит важную информацию. Это 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 уведомление может содержать важную информацию о вашем Premera Blue Cross. 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 заявлении или страховом покрытии через В настоящем уведомлении могут быть указаны ключевые даты. Вам, 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 возможно, потребуется принять меры к определенным предельным 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . срокам для сохранения страхового покрытия или помощи с расходами. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 Вы имеете право на бесплатное получение этой информации и 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 . помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357). ລາວ (Lao): Fa’asamoa (Samoan): ້ ້ ້ ້ ແຈ້ງການນີ ມີ ຂໍ ມູ ນສໍ າຄັ ນ. ແຈ້ງການນີ ອາດຈະມີ ຂໍ ມູ ນສໍ າຄັ ນກ່ ຽວກັບຄໍ າຮ້ອງສະ Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ໝັ ກ ຫືຼ ຄວາມຄຸ້ ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala ວັນທີ ສໍ າຄັ ນໃນແຈ້ງການນີ້ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົ ດ atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua ເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ ມຄອງປະກັນສຸ ຂະພາບ ຫືຼ ຄວາມຊ່ວຍເຫືຼ ອເລື່ ອງ 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 ້ ້ ຄ່ າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ . ທ່ານມີ ສິ ດໄດ້ ຮັບຂໍ ມູ ນນີ ແລະ ຄວາມຊ່ວຍເຫືຼ ອເປັ ນພາສາ aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai ຂອງທ່ານໂດຍບໍ່ ເສຍຄ່ າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357). 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 徶羶ែខមរ (Khmer): ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). េសចកតជី ូនដណំ ឹងេនះ掶នព័ត៌掶ន架៉ ងស޶នំ។ ់ េសចកតីជូនដំណឹងេនះរបែហល ᾶ掶នព័ត៌掶ន架៉ ងសំ޶ន់អពំ ីទរមង់ ែបបបទ ឬζរ殶៉ បរង់ របសអ់ នក㾶មរយៈ Español (Spanish): Premera Blue Cross ។ របែហលᾶ掶ន ζលបរ េចិ ឆទសំ޶ន់េ俅កន ុងេសចកតជី ូន Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a ដណំ ងេនះ។ឹ អនករបែហលᾶរតវζរបេញូ ច ញសមត徶ពថ ដលក់ ណតំៃថ ់ ងᾶកច厶់ ស់ través de Premera Blue Cross. Es posible que haya fechas clave en este 侶侶 េដើមបីនងរកឹ 羶ទកζរ䮶侶ុ 殶៉ បរង់ សខ徶ពរបសុ ់អនក ឬរ厶កជ់ ំនួយេចញៃថល។ aviso. Es posible que deba tomar alguna medida antes de determinadas អនក掶នសទិ ធទទិ ួលព័ត掶នេ៌ នះ និងជំនួយេ俅កន ុង徶羶របស់អនកេ⮶យមនអសិ fechas para mantener su cobertura médica o ayuda con los costos. Usted លយេឡុ ើយ។ សូ មទូរស័ពទ 800-722-1471 (TTY: 800-842-5357)។ tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

ਪ ੰ ਜਾਬੀ (Punjabi): Tagalog (Tagalog): ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ƒ ਤੁਹਾਡੀ Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਕਵਰਜੇ ਅਤ ੇ ਅਰਜੀ ਬਾਰ ੇ ਮਹ ੱ ਤਵਪਰਨੂ ਜਾਣਕਾਰੀ ਹ ੋ ਸਕਦੀ ਹ ੈ . ਇਸ ਨ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ . tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue ਹੋ ਸਕਦੀਆਂ ਹਨ ਜੇਕਰ ਤਸੀੁ ਜਸਹਤ ਕਵਰਜੇ ਿਰੱ ਖਣੀ ਹਵੋ ੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring ਇਛ ੱ ੁਕ ਹ ੋ ਤ拓 ਤਹਾਨ ੁ ੰ ੂ ਅ ੰ ਤਮ ਤਾਰੀਖ਼ ਤ ƒ ਪਿਹਲ拓 ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱ ਕਣ ੁ ਦੀ ਲੋੜ ਹ ੋ ਸਕਦੀ ਹ ੈ ,ਤੁਹਾਨੰ ੂ mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang ਮਫ਼ਤੁ ਿਵੱ ਚ ਤ ੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤ ੇ ਮਦਦ ਪਾਪਤ㘰 ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na 800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 .(Farsi): (TTY: 800-842-5357) فارسی اين اعالميه حاوی اطالعات مھم ميباشد .اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم :(ไทย (Thai تقاضا و يا پ وشش بيمه ای شما از طريق Premera Blue Cross باشد . به تاريخ ھای مھم در ั ประกาศนมข้ี ี ้อมลส ู ําคญ ั ประกาศนอาจม ้ี ีข ้อมลท ู ่ีส ําคญเก ั ่ียวกบการการสม ัครหร ั ือขอบเขตประกน اين اعالميه توجه نماييد .شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه . สขภาพของคุณผ ุาน ่ Premera Blue Cross และอาจมีก ําหนดการในประกาศนี ้ คณอาจจะต ุ ้อง ھای درمانی تان، به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد شما حق اين را داريد که اين اطالعات و ک مک را به زبان خود به طور رايگان دريافت نماييد . برای کسب ี่ ดําเน ินการภายในกาหนดระยะเวลาท ํ ่ีแนนอนเพ ่ ่ือจะร ักษาการประกนส ัขภาพของค ุณหร ุ ือการช ่วยเหล ือท اطالعات با شماره 1471-722-800 (کاربران TTY تماس باشماره 5357-842-800) تماس มคี่้่าใชจาย คณม ุีิิ่ี้ัู้สทธทจะไดรบขอมลและความชวยเหล ่ ื้ีอนในภาษาของคณโดยไม ุ่มค ี่้่าใชจาย โทร برقرار نماييد . 800-722-1471 (TTY: 800-842-5357) Polskie (Polish): To og oszenie mo e zawiera wa ne informacje. To og oszenie mo e ł ż ć ż ł ż Український (Ukrainian): zawiera wa ne informacje odno nie Pa stwa wniosku lub zakresu ć ż ś ń Це повідомлення містить важливу інформацію. Це повідомлення świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na може містити важливу інформацію про Ваше звернення щодо kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie страхувального покриття через Premera Blue Cross. Зверніть увагу на przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub ключові дати, які можуть бути вказані у цьому повідомленні. Існує pomocy zwi zanej z kosztami. Macie Pa stwo prawo do bezp atnej ą ń ł імовірність того, що Вам треба буде здійснити певні кроки у конкретні informacji we własnym języku. Zadzwońcie pod 800-722-1471 кінцеві строки для того, щоб зберегти Ваше медичне страхування або (TTY: 800-842-5357). отримати фінансову допомогу. У Вас є право на отримання цієї

інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за Português (Portuguese): номером телефону 800-722-1471 (TTY: 800-842-5357). Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio Tiếng Việt (Vietnamese): do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông Talvez seja necessário que você tome providências dentro de tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua determinados prazos para manter sua cobertura de saúde ou ajuda de chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). 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 (TTY: 800-842-5357).