Piols) and Astigmatism Correcting Intraocular Lenses (Aciols

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MEDICAL POLICY – 9.03.511 Presbyopia Correcting Intraocular Lenses (PIOLs) and Astigmatism Correcting Intraocular Lenses (ACIOLs)

Ref. Policy: MP-009 Effective Date: Aug. 1, 2021 RELATED MEDICAL POLICIES: Last Revised: July 9, 2021 None Replaces: N/A

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Introduction

Cataracts occur when the eye’s natural lenses become clouded, causing blurry vision and blindness. When cataracts need to be treated with surgery, the natural lens of the eye is replaced with an artificial lens. Presbyopia-correcting intraocular lenses (PIOLs) are artificial lenses that provide near, middle, and distance vision without the need for glasses or contacts after cataract surgery. Astigmatism correcting intraocular lenses (ACIOLs) are artificial lenses that provide the same vision benefits as PIOLs and also correct the irregular curve of the eye’s front surface (astigmatism). This policy describes when presbyopia correcting intraocular enses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs) 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 Presbyopia correcting Presbyopia correcting intraocular lenses (PIOLs) and intraocular lenses (PIOLs) astigmatism correcting intraocular lenses (ACIOLs) may be and astigmatism correcting considered medically necessary for the following indications: intraocular lenses (ACIOLs) • Conventional intraocular lenses (IOLs) during cataract surgery: o If the patient requests ACIOLs or PIOLs, the Plan will pay the portion of the lens cost equal to the cost of IOLs. o The additional costs of the specialty lenses will be the responsibility of the patient. The Plan will pay for insertion of the lenses. • The physician charges (for office procedures) will also be paid as the same level as the conventional IOLs.

Note: See Related Information below for Limitations

Coding

Code Description CPT 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation

66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)

66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation

HCPCS Codes Covered if Selection Criteria are Met (If Appropriate): V2630 Anterior chamber intraocular lens

V2631 Iris supported intraocular lens

V2632 Posterior chamber intraocular lens

Page | 2 of 6 ∞ Code Description Applicable Coding for PIOL and A-CIOL Additional Costs are Not Covered: HCPCS Codes Covered at Cost of Regular IOL: V2787 Astigmatism correcting function of intraocular lens

V2788 Presbyopia correcting function of intraocular lens

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

Limitations

The additional cost of presbyopia correcting intraocular lenses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs), when in excess of the cost of IOLs, is not covered and the patient assumes responsibility for the additional expenses.

Evidence Review

Background

Cataracts cloud the natural lens of the eye, leading to vision loss, and are a result of normal aging. There are approximately 3 million surgeries for cataract removal and replacement with an artificial intraocular lens (IOL) annually in the United States.

Presbyopia-correcting IOLs (PIOLs) provide near, intermediate, and distance vision without the need for eyeglasses and contact lenses following cataract surgery. Similarly, ACIOL provide correction and/or compensate for the imperfect curvature of the cornea (astigmatism).

The Centers for Medicare and Medicaid Services (CMS) announced the intent to provide beneficiaries with the choice to receive PIOLs when they have cataract surgery. In addition, in January 2007, CMS ruled that patients with astigmatism can receive ACIOLs during cataract surgery.

Page | 3 of 6 ∞ The following non-inclusive list of manufacturers are recognized by CMS as resources for PIOLs:

• Cyrstalens™ by Eyeonics, Inc.

• AcrySof RESTOR™ by Alcon, Inc.

• ReZoom™ by Advanced Medical Optics Inc.

ACIOLs:

• Acrysof® Toric IOL (models SN60TS, SN60T4 and SN60T5) manufactured by Alcon Labs, Inc.

• Silicon 2P Toric IOL (models AA4203TF and AA4203TL) manufactured by STARR Surgical

References

1. American Academy of Ophthalmology. Cataract Summary Benchmarks for Preferred Practice Pattern® Guidelines. October 2016. https://www.aao.org/assets/c04b1be2-3120-48ea-8479- 73c117f43247/636150883348030000/summarybenchmarks-fullset-2016-pdf. Accessed July 7, 2021.

2. Ang RE, Martinez GA, Cruz EM, et al. Prospective evaluation of visual outcomes with three presbyopia-correcting intraocular lenses following cataract surgery. Clin Ophthalmol. 2013;7:1811-1823. doi: 10.2147/OPTH.S49848. Epub 2013 Sep 17. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3788698/. Accessed July 7, 2021.

3. Center for Medicare and Medicaid Services (CMS). Medicare Learning Network (MLN) Matters, MM#5527-Revised. Transmittal CR#1228CP. Instructions for Implementing the CMS Ruling CMS-1536-R; Astigmatism-Correcting Intraocular Lens (A-C IOLs). Revised: 04/10/2008. Updated: 08/27/2012. https://www.hhs.gov/guidance/document/instructions-implementation-cms- 1536-r-astigmatism-correcting-intraocular-lens-c-iols . Accessed July 7, 2021.

4. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) No L35091 – Cataract Extraction (including Complex Cataract Surgery. (Contractor: Novitas Solutions, Inc.) Revision Effective Date: 03/28/2019. https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=35091&ContrId=331&ver=65&ContrVer=1&DocType=1&bc=AACAAAAAIAAA&. Accessed July 7, 2021.

5. Centers for Medicare and Medicaid Services (CMS). Medicare Learning Network (MLN) Matters No. MM6630-Revised. : Transmittal R5460TN: Ambulatory Surgical Center Payment Indicator (ASCPI) File Error; and Reiteration of Centers for Medicare and Medicaid Services (CMS) Policy Regarding Beneficiary Liability for V2787 and V2788. Effective Date: 01/01/2009. Updated: 08/07/2012. http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6630.pdf. Accessed July 7, 2021.

6. Centers for Medicare and Medicaid Services (CMS). Medicare Learning Network-Provider Inquiry Assistance (Related to MLN Matters Article # MM5527-Revised): Instructions for Implementing the Centers of Medicare & Medicaid Services (CMS) Ruling 1536-R; Astigmatism-Correcting Intraocular Lens (A-C IOLs), Posted April 30, 2007. https://www.hhs.gov/guidance/document/instructions-implementation-cms-1536-r-astigmatism-correcting- intraocular-lens-c-iols. Accessed July 7, 2021.

7. Centers for Medicare and Medicaid Services (CMS). Medicare Learning Network (MLN) Matters No. MM3927: Transmittal # 636: Implementation of the Centers for Medicare & Medicaid Services (CMS) Ruling 05-01 Regarding Presbyopia-Correcting Intraocular Lenses (IOLs) for Medicare Beneficiaries. Implemented September 6, 2005. http://www.cms.gov/Regulations-and-

Page | 4 of 6 ∞ Guidance/Guidance/Transmittals/2005-Transmittals- Items/CMS043699.html?DLPage=1&DLFilter=IOLs&DLSort=4&DLSortDir=descending. Accessed July 7, 2021.

8. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) No. 80.12. Intra-Ocular Lenses (IOLs), Effective Date: 05/19/1997. http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=239&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed July 7, 2021.

9. CMS Claims Processing Manual: Instructions for Reporting New HCPCS Code V2788 for Presbyopia-Correcting Intraocular Lens (P-C IOLs), Pub-100-04, Transmittal 801, Change Request: 4184. Date: 12/30/2005. http://www.cms.hhs.gov/Transmittals/downloads/R801CP.pdf. Accessed July 7, 2021.

10. CMS Ruling: Requirements for Determining Coverage of Astigmatism-Correcting Intraocular Lenses that Provide Two Distinct Services for the Patient: (1) Restoration of Distance Vision Following Cataract Surgery, and (2) Refractive Correction of Vision Due to Preexisting Astigmatism, with Less Dependency on Surgical Correction, Eyeglasses, or Contact Lenses. Ruling No. CMS 1536-R. January 22, 2007. http://www.cms.hhs.gov/Rulings/downloads/CMS1536R.pdf. Accessed July 7, 2021.

11. CMS Ruling: Requirements for Determining Coverage of Presbyopia-Correcting Intraocular Lenses that Provide Two Distinct Services for the Patient: (1) Restoration of Distance Vision Following Cataract Surgery, and (2) Refractive Correction of Near and Intermediate Vision with Less Dependency on Eyeglasses or Contact Lenses Ruling No. 05-01, May 3, 2005. http://www.cms.hhs.gov/Rulings/downloads/CMSR0501.pdf. Accessed July 7, 2021.

12. Hirnschall N, Gangwani V, Crnej A, et al. Correction of moderate corneal astigmatism during cataract surgery: toric intraocular lens versus peripheral corneal relaxing incisions. J Cataract Refract Surg. 2014 Mar;40(3):354-361. doi: 10.1016/j.jcrs.2013.08.049. Epub 2014 Jan 1. http://www.ncbi.nlm.nih.gov/pubmed/24440102. Accessed July 7, 2021.

13. The FCSO Medicare B Update!: Astigmatism-Correcting Intra-Ocular Lens (A-C IOLs) – Implementation of the CMS 1536 Ruling. June 2007. Vol. 5, No. 6, pages 19-22. http://medicare.fcso.com/Publications_B/2007/141015.pdf. Accessed July 7, 2021.

History

Date Comments 09/16/19 New policy, approved August 13, 2019, effective January 1, 2020. Presbyopia correcting intraocular lenses (PIOLs) and astigmatism correcting intraocular lenses (ACIOLs) may be considered medically necessary post-cataract surgery when criteria are met. Any additional cost above that of standard intraocular lenses (IOLs) is the responsibility of the patient.

08/01/20 Annual Review, approved July 2, 2020. No changes to policy statement.

08/01/21 Annual Review, approved July 9, 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.

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 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 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).