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Utilization Management Policy Name: Deficit Hyperactive Disorder (ADHD) - Enhanced & Essential

Restricted Product(s): Unrestricted/Suggested Alternative(s): generic formulations of ADHD medications unless otherwise noted. Quantity limits apply. • ® • Adhansia XR™ Preferred Brands • / ER (generic Adderall XR®1) • Adderall XR (brand name) • Adzenys XR-ODTTM • Concerta (brand name) • Adzenys ERTM suspension • Vyvanse • Aptensio XR® • ER (generic Concerta®) Preferred Generics • Methylphenidate ER 10 mg & tablet • Amphetamine/dextroamphetamine (generic Adderall) • Cotempla XR ODT™ • /dexmethylphenidate ER (generic • Daytrana® Focalin/Focalin ER) • Dexedrine®/ Dexedrine XR® • SR (generic Intuniv) • DyanavelTM XR • SR (generic Kapvay) • Focalin®/ Focalin XR® • Methylphenidate (generic of Methylin) • Intuniv® • Methylphenidate chews (generic Methylin Chews) • Jornay PMTM • Dextroamphetamine (generic Procentra) • Kapvay® • Dextroamphetamine/dextroamphetamine SR (generic ® • Metadate CD Dexedrine/Dexedrine XR) • Methylin® • Methylphenidate/ methylphenidate SR (generic Ritalin/Ritalin TM • Mydayis LA) ® • Procentra • (generic Strattera) • QuillichewTM • Quillivant XR® TM • Relexxiil • Ritalin®/ Ritalin LA/ Ritalin SR • Strattera® • Zenzedi®

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 1 July 2019

FDA Approved Use: • The treatment of attention deficit hyperactivity disorder (ADHD) Rationale: Adderall XR and Concerta are considered preferred brands due to the high cost of their associated generics. Blue Cross NC is able to provide the brand name product at a better overall price for patients. As a whole, this class of medication is now available in generic forms. This means that the best options for the first trial of an ADHD medication is a generic or one of the preferred brands. Quantity limits have been added to ensure optimal/safe doses for patients. Criteria Summary:

• Generic Adderall XR/Concerta: Clinical contraindication to the brand name product; quantity limits apply. • Other brand name products: Trial and failure of a generic; quantity limits apply. Criteria for Approval of generic Adderall XR/Concerta: 1. The member had a sub-therapeutic or intolerant response (therapeutic failure) to an inactive ingredient of the brand name product, but not present in the generic OR 2. The member has a documented intolerance to an inactive ingredient of the brand name product that are not found in the generic product; OR 3. The prescriber provides a written, clinical, explanation for the medical necessity of the generic product over the brand name product; AND 4. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies (outlined below)*

Duration of Approval: 365 days (1 year)

Criteria for Approval of Restricted Brand Name Products:

1. The patient has experienced a therapeutic failure or inadequate response to TWO, unrestricted, ADHD products; OR 2. The patient had a documented intolerance, hypersensitivity, or FDA labeled contraindication to all the unrestricted ADHD prod ucts; AND 3. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies (outlined below)*

Duration of Approval: 1095 days (3 years)

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 2 July 2019

Criteria for Non-formulary medications – Not otherwise addressed

1. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies (outlined below)*

Quantity Limitations: quantity limitations apply to brand and associated generic products. Medication Quantity per Day Max Daily Dose/Maximum Dose Studied (unless specified) Per FDA Label

Adderall (amphetamine/ dextroamphetamine) 5mg 3 ADHD (Pediatric and Adults): Not to exceed Adderall (amphetamine/ dextroamphetamine) 7.5mg 3 40mg/day except only in rare cases Adderall (amphetamine/ dextroamphetamine) 10mg 3 Adderall (amphetamine/ dextroamphetamine) 12.5mg 3 : 60mg/day in divided doses Adderall (amphetamine/ dextroamphetamine) 15mg 2 Adderall (amphetamine/ dextroamphetamine) 20mg 3 Adderall (amphetamine/ dextroamphetamine) 30mg 2

Adderall XR (amphetamine/ dextroamphetamine extended release) 5mg 1 Pediatric (6-17 yoa): 10mg to 40mg per day Adderall XR (amphetamine/ dextroamphetamine extended release) 10mg 1 studied; no adequate evidence that doses Adderall XR (amphetamine/ dextroamphetamine extended release) 15mg 1 greater than 20mg/day conferred additional Adderall XR (amphetamine/ dextroamphetamine extended release) 20mg 1 benefit Adderall XR (amphetamine/ dextroamphetamine extended release) 25mg 1 Adderall XR (amphetamine/ dextroamphetamine extended release) 30mg 1 Adults: 20mg to 60mg per day studied; no adequate evidence that doses greater than 20mg/day conferred additional benefit

Adhansia XR (methylphenidate extended release) 25mg 1 Per FDA label: Dosages above 85 mg daily in Adhansia XR (methylphenidate extended release) 35mg 1 adults and 70 mg and above daily in pediatric Adhansia XR (methylphenidate extended release) 45mg 1 patients are associated with disproportionate Adhansia XR (methylphenidate extended release) 55mg 1 increases in the incidence of certain adverse Adhansia XR (methylphenidate extended release) 70mg 1 reactions.

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 3 July 2019

Adhansia XR (methylphenidate extended release) 85mg 1

Adzenys ER (amphetamine ER suspension) 1.25mg/mL 15.1mL Pediatric (6-12 yoa): 18.8 mg once daily

Pediatric (13-17 yoa): 12.5 mg once daily

Adults: 18.8 mg once daily

Adzenys XR-ODT (amphetamine ER dispersible) 3.1mg 1 Pediatric (6-12 yoa): 18.8 mg once daily Adzenys XR-ODT (amphetamine ER dispersible) 6.3mg 1 Adzenys XR-ODT (amphetamine ER dispersible) 9.4 mg 1 Pediatric (13-17 yoa): 12.5 mg once daily Adzenys XR-ODT (amphetamine ER dispersible) 12.5mg 1 Adzenys XR-ODT (amphetamine ER dispersible) 15.7mg 1 Adults: 18.8 mg once daily Adzenys XR-ODT (amphetamine ER dispersible) 18.8mg 1

Aptensio XR (methylphenidate extended release) 10mg 1 ADHD (Pediatric and Adults): Doses greater Aptensio XR (methylphenidate extended release) 15mg 1 than 60mg per day have not been studied and Aptensio XR (methylphenidate extended release) 20mg 1 are not recommended Aptensio XR (methylphenidate extended release) 30mg 1 Aptensio XR (methylphenidate extended release) 40mg 1 Aptensio XR (methylphenidate extended release) 50mg 1 Aptensio XR (methylphenidate extended release) 60mg 1

Concerta (methylphenidate extended release) 18mg/ and non-equivalent 1 Pediatric (6-12yoa): Doses greater than 54mg methylphenidate extended release Concerta generic per day have not been studied and are not Concerta (methylphenidate extended release) 27mg/ and non-equivalent 1 recommended methylphenidate extended release Concerta generic Concerta (methylphenidate extended release) 36mg/ and non-equivalent 2 Pediatric (13-17yoa): Doses greater than methylphenidate extended release Concerta generic 72mg per day have not been studied and are Concerta (methylphenidate extended release) 54mg/ and non-equivalent 1 not recommended methylphenidate extended release Concerta generic

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 4 July 2019

Adults (18-65yoa): Doses greater than 72mg per day have not been studied and are not recommended

Cotempla XR-ODT (methylphenidate ER ODT) 8.6mg 1 Daily doses above 51.8 mg have not been Cotempla XR-ODT (methylphenidate ER ODT) 17.3mg 2 studied and are not recommended. Cotempla XR-ODT (methylphenidate ER ODT) 25.9mg 2

Daytrana (methylphenidate transdermal patch) 10mg/9hr 1 Doses greater than 30mg/9hr were not studied Daytrana (methylphenidate transdermal patch) 15mg/9hr 1 Daytrana (methylphenidate transdermal patch) 20mg/9hr 1 Daytrana (methylphenidate transdermal patch) 30mg/9hr 1

Dextroamphetamine (DextroStat) 5mg 2 Narcolepsy: 5-60mg/day in divided doses

Dextroamphetamine (DextroStat) 10mg 6 ADHD: 40mg/day

Dexedrine (dextroamphetamine extended release) 5mg 3 ADHD: Per FDA label, only in rare cases will it be necessary to exceed a total of 40 mg per Dexedrine (dextroamphetamine extended release) 10mg 4 day. Dexedrine (dextroamphetamine extended release) 15mg 4

Dyanavel XR (amphetamine extended release) 2.5mg per 1mL 8 mL ADHD: Per FDA label, daily doses above 20mg are not recommended.

Focalin (dexmethylphenidate) 2.5mg 3 Per FDA label, the maximum recommended Focalin (dexmethylphenidate) 5mg 3 dose is 20mg/day (10mg twice daily). Focalin (dexmethylphenidate) 10mg 2

Focalin XR (dexmethylphenidate extended release) 5mg 1 Focalin XR (dexmethylphenidate extended release) 10mg 1

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 5 July 2019

Focalin XR (dexmethylphenidate extended release) 15mg 1 Per FDA label, doses above 30mg/day in Focalin XR (dexmethylphenidate extended release) 20mg 1 pediatrics and 40mg/day in adults have not Focalin XR (dexmethylphenidate extended release) 25mg 1 been studied and are not recommended. Focalin XR (dexmethylphenidate extended release) 30mg 1 Focalin XR (dexmethylphenidate extended release) 35mg 1 Focalin XR (dexmethylphenidate extended release) 40mg 1

Intuniv (guanfacine extended release) 1mg 1 Per the FDA label, doses above 4mg/day Intuniv (guanfacine extended release) 2mg 1 have not been systematically studied in Intuniv (guanfacine extended release) 3mg 1 controlled clinical studies. Intuniv (guanfacine extended release) 4mg 1

Jornay PM (methylphenidate extended release) 20 mg 1 Per the FDA label, daily dosage above Jornay PM (methylphenidate extended release) 40 mg 1 100mg/day is not recommended. Jornay PM (methylphenidate extended release) 60 mg 1 Jornay PM (methylphenidate extended release) 80 mg 1 Jornay PM (methylphenidate extended release) 100 mg 1

Kapvay (clonidine extended release) 0.1mg 4 Recommended dose is 0.2mg given twice daily

Metadate CD (methylphenidate extended release) 10mg 1 Per FDA label, daily dosage above 60mg is Metadate CD (methylphenidate extended release) 20mg 1 not recommended. Metadate CD (methylphenidate extended release) 30mg 1 Metadate CD (methylphenidate extended release) 40mg 1 Metadate CD (methylphenidate extended release) 50mg 1 Metadate CD (methylphenidate extended release) 60mg 1

Metadate ER (methylphenidate extended release) 10mg 3 Children ≥6yo: Per FDA label, daily dosage Metadate ER (methylphenidate extended release) 20mg 3 above 60mg/day is not recommended

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 6 July 2019

Methylin Chew Tabs (methylphenidate) 2.5mg 3 Children ≥6yo: Per FDA label, daily dosage Methylin Chew Tabs (methylphenidate) 5mg 3 above 60mg/day is not recommended. Methylin Chew Tabs (methylphenidate) 10mg 6 Methylin Solution (methylphenidate) 5mg/5mL 15 mL Methylin Solution (methylphenidate) 10mg/5mL 30 mL

Adults: Doses above 50 mg daily have shown Mydayis 12.5 mg extened-release capsule 1 no additional clinically meaningful benefit (mixed salts of a single-entity amphetamine product) Mydayis 25 mg extened-release capsule 1 Pediatric (13-17): Doses higher than 25 mg (mixed salts of a single-entity amphetamine product) have not been evaluated in clinical trials in Mydayis 37.5 mg extened-release capsule 1 pediatric patients (mixed salts of a single-entity amphetamine product) Mydayis 50 mg extened-release capsule 1 (mixed salts of a single-entity amphetamine product)

Procentra (dextroamphetamine) 5mg/5mL 60 mL ADHD: Per FDA label, only in rare cases will it be necessary to exceed a total of 40mg/day.

Quillichew ER (methylphenidate extended release) 20mg 1 Per the FDA label, daily dosage above 60 mg Quillichew ER (methylphenidate extended release) 30mg 2 is not recommended. Quillichew ER (methylphenidate extended release) 40mg 1

Quillivant XR (methylphenidate extended release) 25 mg/5 mL 60 mg or 12 mL ADHD: Per FDA label, dosage >60mg/day is not recommended. Doses up to 60mg/day were studied in clinical trials.

Relexxii (methylphenidate ER Osmotic Release) 72mg 1 Pediatric (13-17yoa): Doses greater than 72mg per day have not been studied and are not recommended

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 7 July 2019

Adults (18-65yoa): Doses greater than 72mg per day have not been studied and are not recommended

Ritalin (methylphenidate) 5mg 3 Children ≥6yo: Per FDA label, daily doses Ritalin (methylphenidate) 10mg 3 above 60mg/day is not recommended. Ritalin (methylphenidate) 20mg 3

Ritalin LA (methylphenidate extended release) 10mg 1 Per FDA label: daily dosage above 60mg is Ritalin LA (methylphenidate extended release) 20mg 1 not recommended. Ritalin LA (methylphenidate extended release) 30mg 2 Ritalin LA (methylphenidate extended release) 40mg 1 Ritalin LA (methylphenidate extended release) 60mg 1

Ritalin SR (methylphenidate extended release) 20mg 3 Children ≥6yo: Per FDA label, daily doses above 60mg/day is not recommended.

Strattera (atomoxetine) 10mg 2 Children and adolescents: Doses of 0.5 to Strattera (atomoxetine) 18mg 2 1.8mg/kg/day were studied; 1.8mg/kg/day Strattera (atomoxetine) 25mg 2 dose did not provide any additional benefit Strattera (atomoxetine) 40mg 2 over that observed with the 1.2mg/kg/day Strattera (atomoxetine) 60mg 2 dose. Strattera (atomoxetine) 80mg 1 Strattera (atomoxetine) 100mg 1 Adults: Doses of 60 to 120mg/day were studied; mean final dose was approximately 95mg/day.

Vyvanse (lisdexamphetamine) capsule or chew 10mg 1 Per the FDA label, doses >70mg/day were not Vyvanse (lisdexamphetamine) capsule or chew 20mg 1 studied in clinical trials. Only once daily doses Vyvanse (lisdexamphetamine) capsule or chew 30mg 1 were studied. Vyvanse (lisdexamphetamine) capsule or chew 40mg 1 Vyvanse (lisdexamphetamine) capsule or chew 50mg 1

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 8 July 2019

Vyvanse (lisdexamphetamine) capsule or chew 60mg 1 Vyvanse (lisdexamphetamine) capsule 70mg 1

Zenzedi (dextroamphetamine) 2.5mg 3 ADHD: Per FDA label, only in rare cases will it Zenzedi (dextroamphetamine) 5mg 2 be necessary to exceed a total of 40mg/day. Zenzedi (dextroamphetamine) 7.5mg 8 Zenzedi (dextroamphetamine) 10mg 6 Zenzedi (dextroamphetamine) 15mg 2 Zenzedi (dextroamphetamine) 20mg 3 Zenzedi (dextroamphetamine) 30mg 2

Quantity Limit Exception Criteria:

1. The quantity (dose) requested is for documented titration purposes at the initiation of therapy (authorization for a 90 day titration period); AND 2. The prescribed dose cannot be achieved using a lesser quantity of a higher strength; AND 3. The quantity (dose) requested does not exceed the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert; OR 4. If the quantity (dose) requested exceeds the maximum FDA labeled dose, when specified, or to the safest studied dose per the manufacturer’s product insert, then the prescriber must submit documentation in support of therapy with a higher dose for the intended diagnosis (submitted documentation may include medical records OR fax form which reflects medical record documentation that shows the length of time the requested dose has been used, and what other medications and doses have been tried and failed).

Duration of Approval: 1095 days (3 years)

*Non-formulary Exception Criteria Non-Formulary Exception criteria applies on formularies which exclude requested product(s). Satisfactory completion of criteria points (above) may satisfy some, or all, portions of the Non-Formulary Exception Criteria. This criteria is summarized as: a) Request must be for an FDA approved indication; AND

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 9 July 2019

b) Patient must have a trial and failure of up to TWO formulary medications or a clinical contraindication/intolerance to those medications not tried.

References: all information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information: Originated: August 2015; Last updated; Jul 2019

Jul 2019: Criteria update: Adhansia XR added to the policy. Jul 2019: Criteria Change: Increased requirement to a trial of two alternatives for approval. Added methylphenidate ER 10mg to restriction. May 2019: Criteria update: Jornay PM added to the policy. Jan 2019: Vyvanse restriction removed for the Enhanced and Essential formularies Jul 2018: Methylphenidate ER Osmotic Release 72mg is no longer restricted due to generic status (MSC Y) Apr 2018: Net Results removed from policy. Jan 2018: Added new to market drug Methylphenidate ER Osmotic Release 72mg and Adzenys ER suspension to criteria Dec 2017: Extended authorization lengths to 3 years for step and quantity approvals Aug 2017: Added new to market drug, Cotempla XR ODT. Jul 2017: Added new to market drug, Mydayis. Jun 2017: Reformatting, no change to criteria; atomoxetine added as an unrestricted product in alignment with its release. May 2017: Methylphenidate hcl chews added to restriction due to sole manufacturer in the market. Apr 2017: Restrictions placed on select brand name products; Standalone criteria for methylphenidate and amphetamine/dextroamphetamine ER consolidated into one criteria. Jan 2017: Reviewed for ASO Net Results and Essential Formularies; Non-formulary verbiage added. Mar 2016: Added new to market drug, Adzenys XR-ODT Feb 2016: Added new to market medications, Dynavel XR and Quillichew ER to the policy. Aug 2015: Revision - Evekeo and Desoxyn removed from the ADHD QL criteria and added to their own program with ADHD QL and Short Term PA

Non-Discrimination and Accessibility Notice Discrimination is Against the Law

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 10 July 2019

• Blue Cross and Blue Shield of North Carolina (“BCBSNC”) complies with applicable Federal civil rights laws and does not discr iminate on the basis of race, color, national origin, age, disability, or sex. • BCBSNC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. BCBSNC: ▪ Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) ▪ Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages • If you need these services, contact Customer Service 1-888-206-4697, TTY and TDD, call 1-800-442-7028.

• If you believe that BCBSNC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: ➢ BCBSNC, PO Box 2291, Durham, NC 27702, Attention: Civil Rights Coordinator- Privacy, Ethics & Corporate Policy Office, Telephone 919- 765-1663, Fax 919-287-5613, TTY 1-888-291-1783 [email protected] • You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator - Privacy, Ethics & Corporate Policy Office is available to help you.

• You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537- 7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 11 July 2019

• This Notice and/or attachments may have important information about your application or coverage through BCBSNC. Look for key dates. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call Customer Service 1-888-206-4697.

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-206-4697 (TTY: 1-800-442-7028). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-206-4697 (TTY: 1-800-442-7028). 注意:如果您講廣東話或普通話, 您可以免費獲得語言援助服務。請致電 1-888-206-4697 (TTY:1-800-442-7028)。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-206-4697 (TTY: 1-800-442-7028). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-206-4697 (TTY: 1- 800-442-7028)번으로 전화해 주십시오. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-888-206-4697 (ATS : 1-800-442-7028). ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 4697-206-888-1. المبرقة الكاتبة: 1-800-442-7028. LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-888-206-4697 (TTY: 1-800-442-7028). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-206-4697 (телетайп: 1-800-442-7028). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-206-4697 (TTY: 1- 800-442-7028).

BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 12 July 2019

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:સુ쫍કુ ભાષા સહાય સેવાઓ તમારા માટે ઉપલ닍ધ છે. ફોન કરો 1-888-206-4697 (TTY: 1-800-442-7028).

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BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective ow ners. Page 13 July 2019