BENEFIT COVERAGE GUIDELINE – 10.01.521 Routine Vision Care
Effective Date: Mar. 1, 2021 RELATED MEDICAL POLICIES / GUIDELINES: Last Revised: Feb. 2, 2021 9.03.508 Orthoptic and Vision Therapy, Visual Perceptual Training, Vision Replaces: N/A Restoration Therapy, and Neurovisual Rehabilitation
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BENEFIT COVERAGE CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY
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Introduction
Vision services is a broad term that means care of the eyes. Vision services are usually either “routine” or “medical”. Although the exams and activities may be similar, the reason for the visit determines whether it’s a routine or medical visit. Visiting an ophthalmologist (a medical doctor) does not necessarily make the visit or exam “medical” in nature.
Benefits vary depending on the reason for the examination.
• Routine eye exam: Routine exams are often done to find the cause of blurry vision. They produce a diagnosis such as myopia (nearsightedness), hyperopia (farsightedness), presbyopia (inability to focus on near objects), or astigmatism (irregular curvature of the clear cover of the eye, the cornea). After a routine exam, a prescription for corrective lenses (glasses) may be given to the patient. If the plan offers a routine vision benefit, the routine services are covered at the level stated in the member’s contract. If the plan does not offer a routine vision benefit, routine services are not covered.
• Medical eye exam: Medical exams are to diagnose, treat, or monitor eye conditions such as aniridia, aniseikonia, anisometropia, aphakia, bullous keratopathy, congenital cataract, corneal abrasion, corneal disorders, corneal ulcer, irregular astigmatism, keratoconus, pathological myopia, post-traumatic disorders, progressive high (degenerative) myopia, recurrent erosion of cornea, Sjogren disease, or tear film insufficiency. Medical vision services are covered under the medical benefit. Depending on the specific plan, glasses or contact lenses may be covered under the medical benefit if they are prescribed for a medical problem.
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.
Benefit Coverage Criteria
Procedure / Service Coverage Criteria Routine Vision Services If the member has a vision services benefit, the plan covers routine eye services listed in the Coding table below. Hardware, such as glasses or contacts, is covered at the level stated in the member’s contract. • When the plan does not have a routine vision services benefit, eye refractions and examinations classified as routine are Not Covered. This includes services to prescribe, fit, or change eyeglasses or contact lenses. Medical Vision Services Visual exams may be covered under the medical benefit when a disease/condition of the eye is found or is reasonably suspected, or when the member is undergoing long-term treatment with a high-risk medication. • The medical record must clearly document the specific condition, or the high-risk medication being used. • Vision hardware also may be considered a medical treatment and applied to the medical equipment and supplies benefit in some cases, such as the following: o Aphakia (see Definition of Terms) o Keratoconus (see Definition of Terms)
Note: Medical diagnoses that are covered may vary depending on a member’s specific plan.
Coding
Page | 2 of 7 ∞ Codes listed in this guideline are for reference only. Listing of a code does not imply that the service described by this code is a covered or non-covered service. Coverage is determined by the member-specific contract and applicable laws that may require coverage for a specific service. Inclusion of a code does not imply any right to reimbursement or guarantee of claims payment. Benefits are subject to all terms and limitations in the member contract.
The following codes have been classified as routine vision services.
Code Description ICD-10 Diagnosis Codes H52.00 Hypermetropia, unspecified eye
H52.01 Hypermetropia, Right eye
H52.02 Hypermetropia, Left eye
H52.03 Hypermetropia, Bilateral eye
H52.10 Myopia, unspecified eye
H52.11 Myopia, right eye
H52.12 Myopia, left eye
H52.13 Myopia, bilateral eye
H52.201 Unspecified Astigmatism, right eye
H52.202 Unspecified Astigmatism, left eye
H52.203 Unspecified Astigmatism, bilateral
H52.209 Unspecified Astigmatism, unspecified eye
H52.211 Irregular Astigmatism, right eye
H52.212 Irregular Astigmatism, left eye
H52.213 Irregular Astigmatism, bilateral
H52.219 Irregular Astigmatism, unspecified eye
H52.221 Regular Astigmatism, right eye
H52.222 Regular Astigmatism, left eye
H52.223 Regular Astigmatism, bilateral
H52.229 Regular Astigmatism, unspecified eye
Page | 3 of 7 ∞ Code Description H52.31 Anisometropia
H52.32 Aniseikonia
H52.4 Presbyopia
H52.511 Internal ophthalmoplegia (complete) (total), right eye
H52.512 Internal ophthalmoplegia (complete) (total), left eye
H52.513 Internal ophthalmoplegia (complete) (total), bilateral
H52.519 Internal ophthalmoplegia (complete) (total), unspecified eye
H52.521 Paresis of accommodation, right eye
H52.522 Paresis of accommodation, left eye
H52.523 Paresis of accommodation, bilateral
H52.529 Paresis of accommodation, unspecified eye
H52.531 Spasm of accommodation, right eye
H52.532 Spasm of accommodation, left eye
H52.533 Spasm of accommodation, bilateral
H52.539 Spasm of accommodation, unspecified eye
H52.6 Other disorders of refraction
H52.7 Unspecified disorder of refraction
H53.7 Unspecified disorder of refraction
H53.71 Glare Sensitivity
H53.72 Impaired contrast Sensitivity
Z13.5 Encounter for screening for eye and ear disorders
Z01.00 Encounter for examination of eyes and vision without abnormal findings (Encounter for examination of eyes and vision NOS)
Z01.01 Encounter for examination of eyes and vision with abnormal findings (Use additional code to identify abnormal findings)
Z46.0 Encounter for fitting and adjustment of spectacles and contact lenses
Page | 4 of 7 ∞ Related Information
Definition of Terms
Aniridia: The absence of part or all of the iris, the colored part of the eye.
Aniseikonia: An ocular defect in which the images on the retinas are different in size.
Anisometropia: A condition in which the eyes have different refractive power causing the eyes to focus unevenly.
Aphakia: The absence of the lens of the eye. Aphakia may be caused by a genetic defect, surgical removal of a cataract, or an injury.
Bullous keratopathy: An eye condition in which the cornea is permanently swollen due to damage of the inner layer of the cornea (endothelium) that is not pumping fluid properly. This damage may be caused by trauma, glaucoma, or postoperative inflammation.
Keratoconus: A progressive disease in which the cornea, which is normally curved over the front of the eye, bulges and becomes more cone shaped. It can affect one or both eyes.
Ophthalmologist: A doctor of medicine (MD) or a doctor of osteopathy (DO) who specializes in vision care and is commonly called an eye doctor. An ophthalmologist is licensed to practice medicine and surgery and can treat all eye diseases, perform eye surgery, and prescribe corrective lenses.
Ophthalmology: The branch of medicine related to the structure, function, diseases, and refractive errors of the eye.
Optician: A trained technician to verify and fit glasses, frames, contact lenses and other devices to correct eyesight. Opticians use the prescriptions created by ophthalmologists and optometrists but do not perform eye exams.
Optometrist: A doctor of optometry (OD) who is also commonly called an eye doctor. An optometrist is licensed to practice optometry rather than general medicine. An optometrist performs eye exams, conducts vision tests, prescribes and dispenses corrective lenses, detects certain eye abnormalities, and prescribes medication for certain eye disease. They do not do eye surgery.
Refraction: An exam to measure a refractive error of the eye and determine the prescription for glasses or contact lenses.
Refractive error: In a refractive error of the eye, the light is not bending correctly as it passes through the cornea and retina. The result is blurred vision.
Page | 5 of 7 ∞
Evidence Review
N/A
References
N/A
History
Date Comments 08/01/16 New benefit coverage guideline, add to Administrative section. Approved July 12, 2016. Clarification provided on routine vision services versus medical vision services; codes listed as reference to illustrate those often denoting routine vision services.
08/16/16 Coding update. Added ICD-10 diagnosis codes H53.041, H53.042, H53.043, and H53.049 effective 10/01/16.
05/01/17 Annual Review, approved April 11, 2017. No change in benefit coverage guideline statements.
10/01/17 Added ICD-10 diagnosis code H52.7.
11/23/17 Coding update. Removed ICD-10 diagnosis codes H50.00 - H50.18 and H53.001 - H53.039.
12/05/17 Coding update. Removed ICD-10 diagnosis codes H53.041, H53.042, H53.043, and H53.049.
02/01/18 Annual Review, approved January 30, 2018. No change in benefit coverage guidelines statements.
04/17/18 Coding update, removed diagnosis codes H53.8 and H53.9.
02/01/19 Annual Review, approved January 4, 2019. Benefit coverage guideline reviewed. No change to content.
Page | 6 of 7 ∞ Date Comments 03/01/20 Annual Review, approved February 4, 2020. Guideline reviewed. Guideline statements unchanged.
05/01/20 Interim Review, approved April 23, 2020. Diagnoses listed in the Medical eye exam section were clarified.
09/01/20 Coding update. Removed diagnosis codes H53.141, H53.142, H53.143 and H53.149.
03/01/21 Annual Review, approved February 2, 2021. Benefit coverage guideline reviewed. Guideline statements unchanged.
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 does not apply to Medicare Advantage.
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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架៉ ងសនំ។ ់ េសចកតីជូនដំណឹងេនះរបែហល ᾶ掶នព័ត៌掶ន架៉ ងសំន់អពំ ីទរមង់ ែបបបទ ឬζរ殶៉ បរង់ របសអ់ នក㾶មរយៈ Español (Spanish): Premera Blue Cross ។ របែហលᾶ掶ន ζលបរ េចិ ឆទសំន់េ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).