5.01.620 Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders

PHARMACY / MEDICAL POLICY – 5.01.620 Vascular Endothelial Growth Factor (VEGF) Receptor Inhibitors for Ocular Disorders

Effective Date: Mar. 3, 2021 RELATED MEDICAL POLICIES: Last Revised: Nov. 10, 2021 None Replaces: N/A

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Introduction

Age-related macular degeneration is due to a small area of the retina called the macula being impaired as people age. This results in loss of vision overtime. There are two types of age- related macular degeneration called the dry form and the wet form. The dry form is caused by deposits in the macula and the wet form is caused by the creation of new blood vessels underneath the macula. There are drugs called vascular endothelial growth factor (VEGF) receptor inhibitors that interfere with the growth of blood vessels in the wet form of age-related macular degeneration. These drugs can also help other conditions of the eye that are related to the blood vessels. This policy describes when Beovu®, Eylea®, Lucentis®, and Macugen® 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

Drug Medical Necessity Beovu® (brolucizumab- Beovu® (brolucizumab-dbll) may be considered medically dbll) necessary for the following: • Neovascular (Wet) Age-Related Macular Degeneration (AMD) AND • The patient has tried bevacizumab and had an inadequate response or intolerance to bevacizumab AND • Beovu® (brolucizumab-dbll) is not used in combination with Eylea® (aflibercept), Lucentis® (ranibizumab), or Macugen® (pegaptanib)

Note: For bevacizumab no review is needed for eye-related injections. Reference to bevacizumab includes the biosimilars (eg, bevacizumab- bvzr and bevacizumab-awwb)

Eylea® (aflibercept) Eylea® (aflibercept) may be considered medically necessary for the following: • Neovascular (Wet) Age-Related Macular Degeneration (AMD) • Macular Edema Following Retinal Vein Occlusion (RVO) • Diabetic Macular Edema (DME) • Diabetic Retinopathy (DR) AND • The patient has tried bevacizumab and had an inadequate response or intolerance to bevacizumab AND • Eylea® (aflibercept) is not used in combination with Beovu® (brolucizumab-dbll), Lucentis® (ranibizumab), or Macugen® (pegaptanib)

Note: For bevacizumab no review is needed for eye-related injections. Reference to bevacizumab includes the biosimilars (eg, bevacizumab- bvzr and bevacizumab-awwb)

Lucentis® (ranibizumab) Lucentis® (ranibizumab) may be considered medically necessary for the following: • Neovascular (Wet) Age-Related Macular Degeneration (AMD) • Macular Edema Following Retinal Vein Occlusion (RVO) • Diabetic Macular Edema (DME)

Page | 2 of 10 ∞ Drug Medical Necessity • Diabetic Retinopathy (DR) • Myopic Choroidal Neovascularization (mCNV) AND • The patient has tried bevacizumab and had an inadequate response or intolerance to bevacizumab AND • Lucentis® (ranibizumab) is not used in combination with Beovu® (brolucizumab-dbll), Eylea® (aflibercept), or Macugen® (pegaptanib)

Note: For bevacizumab no review is needed for eye-related injections. Reference to bevacizumab includes the biosimilars (eg, bevacizumab- bvzr and bevacizumab-awwb)

Macugen® (pegaptanib) Macugen® (pegaptanib) may be considered medically necessary for the following: • Neovascular (Wet) Age-Related Macular Degeneration (AMD) AND • The patient has tried bevacizumab and had an inadequate response or intolerance to bevacizumab AND • Macugen® (pegaptanib) is not used in combination with Beovu® (brolucizumab-dbll), Eylea® (aflibercept), or Lucentis® (ranibizumab)

Note: For bevacizumab no review is needed for eye-related injections. Reference to bevacizumab includes the biosimilars (eg, bevacizumab- bvzr and bevacizumab-awwb)

Drug Investigational As listed All other uses of the drugs listed for conditions not outlined in this policy are considered investigational.

Page | 3 of 10 ∞ Length of Approval Approval Criteria Initial authorization All drugs listed in policy may be approved up to 12 months. Re-authorization criteria Future re-authorization of all drugs listed in policy may be approved up to 12 months as long as the drug-specific coverage criteria are met and chart notes demonstrate that the patient continues to show a positive clinical response to therapy.

Documentation Requirements The patient’s medical records submitted for review for all conditions should document that medical necessity criteria are met. The record should include the following: • Office visit notes that contain the diagnosis, relevant history, medication history, and physical evaluation AND • Documentation that the patient has tried bevacizumab and had an inadequate response or intolerance to bevacizumab

Coding

Code Description HCPCS J0178 Injection, aflibercept, (Eylea®) 1 mg

J0179 Injection, brolucizumab-dbll, (Beovu®) 1 mg

J2503 Injection, pegaptanib sodium, (Macugen®) 0.3 mg

J2778 Injection, ranibizumab, (Lucentis®) 0.1 mg

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

Page | 4 of 10 ∞ Benefit Application

All medications listed in this policy are managed through both the Pharmacy benefit and Medical benefit.

Evidence Review

Background

Age-related macular degeneration is a disorder of the macula that is characterized by the presence of at least intermediate-size drusen (>63µm in diameter), retinal pigment epithelium (RPE) abnormalities (i.e. hypopigmentation or hyperpigmentation), and/or the presence of geographic atrophy of the RPE, choroidal neovascularization ([CNV] exudative, wet), polypoidal choroidal vasculopathy (PCV), reticular pseudodrusen, or retinal angiomatous proliferation. Choroidal neovascularization or wet AMD (nAMD), is characterized by growth of abnormal vessels into the subretinal space, typically from the choroidal circulation, but sometimes from the retinal circulation. It is estimated that 0.46% of the global population has nAMD based on results from a pooled meta-analysis. However, nAMD accounts for more than 80% of AMD cases that result in severe visual loss or legal blindness. The greatest risk factor for AMD is aging, but other risk factors include Caucasian race, smoking, alcohol use, diets deficient in fruits, vegetables, and fish, family history, cardiovascular disease, AIDS, chronic myeloproliferative diseases, and cataract surgery. Thus, the prevalence of AMD in the United States is expected to increase to 22 million patients by 2050.

Summary of Evidence

Meaningful Differences in Efficacy in Clinical Trials

Treatment with a VEGF inhibitor has demonstrated favorable visual acuity outcomes compared to no treatment for nAMD. Efficacy outcomes are relatively similar, in terms of visual acuity, measured by stable vision (<15 letter loss) and mean gain in BCVA ETDRS letters from baseline with aflibercept, bevacizumab, brolucizumab, and ranibizumab. Pegaptanib did not demonstrate improvements in visual acuity, as evidenced by only 55% of patients experiencing vision loss of <15 letters. On the other hand, aflibercept has demonstrated statistically significant improvements in anatomical outcomes, as assessed by mean reductions in CRT.

Page | 5 of 10 ∞

Meaningful Differences in Safety Profiles

Serious adverse event rates were relatively similar between aflibercept, bevacizumab, and ranibizumab in clinical trials. While adverse event rates between brolucizumab and aflibercept were similar in clinical trials, the ASRS released a statement in February 2020 regarding the safety of brolucizumab due to 14 cases of vasculitis (11 of which were designated occlusive retinal vasculitis) being reported since its FDA approval in October 2019. Higher rates of serious adverse events were observed in the pegaptanib clinical trials than the other VEGF inhibitor therapies.

Real World Comparative Effectiveness

A Cochrane, systematic review, was published comparing the efficacy and safety of VEGF inhibitors (pegaptanib, ranibizumab, and bevacizumab) to the control of no treatment for the indication of neovascular age-related macular degeneration.

Vascular Endothelial Growth Factor Inhibitor Treatment Versus Control for Neovascular Age-Related Macular Degeneration

• Mean change in visual acuity was measured by average mean gain in early treatment diabetic retinopathy study (ETDRS) letters of 6.72, 17.80, 12.60 letters with pegaptanib, ranibizumab, and bevacizumab, respectively. In comparison, the control group was observed to have mean losses between 10-16 ETDRS letters. • Mean differences of combined (pegaptanib, ranibizumab, and bevacizumab) National Eye Institute-Visual Function Questionnaire (NEI-VFQ) scores compared to the control were 6.69 points higher. • A risk ratio range of 0.17 to 2.08 for the occurrence of serious systemic adverse events was calculated for patients receiving VEGF inhibitor therapy, relative to the control. • A risk ratio range of 0.52 to 2.71 for the occurrence of serious ocular adverse events at 1 year was calculated for patients receiving VEGF inhibitor therapy, relative to the control. • Thus, VEGF inhibitor treatment appears to significantly improve visual acuity and may reduce adverse events compared to the control of no treatment for nAMD with moderate to high grades of evidence.

Page | 6 of 10 ∞ Bevacizumab Versus Ranibizumab for Neovascular Age Related Macular Degeneration

• The risk ratio for a gain of >15 letters visual acuity at 1 year was 0.95 for bevacizumab compared to ranibizumab. • The risk ratio for a loss of <15 letters visual acuity at 1 year was 1.00 for bevacizumab compared to ranibizumab. • Mean difference in visual acuity, as measured by number of ETDRS letters at 1 year, was calculated to be -0.6 letters with bevacizumab compared to ranibizumab. • Mean difference in reduction of central retinal thickness (CRT) at year 1 was calculated to be -11.6µm with bevacizumab compared to ranibizumab • A risk ratio range of 0.96 to 1.02 was calculated for having no problems in quality of life domains at 1 year with bevacizumab compared to ranibizumab. • The risk ratio for serious systemic adverse events at 1 year was calculated to be 1.15 with bevacizumab compared to ranibizumab. • A risk ratio range of 0.51 to 7.05 for serious ocular adverse events at 1 year was calculated when comparing bevacizumab and ranibizumab. Individually, their risks were observed to be <5 events per 1000 patients. • The efficacy and safety outcomes between bevacizumab and ranibizumab appear to be comparable with moderate to high quality grades of evidence.

Quality of Evidence Supporting Interchangeability of These Agents

The American Academy of Ophthalmology (AAO) Preferred Practice Pattern Guidelines for AMD, updated in October 2019, considers aflibercept, bevacizumab, and ranibizumab as first-line VEGF inhibitors for the treatment of nAMD and that the selection of agent should be individually tailored based on discussions between the patient and physician.

In a combined meta-analysis and systematic review, the authors reviewed the anatomical and functional outcomes of switching from bevacizumab and ranibizumab to aflibercept for the treatment of nAMD. The authors included 28 studies and results showed small improvements in best corrected visual acuity (BCVA) of 1.11 letters (95% CI -0.25 to 2.46, P=0.17) at 6 months and 0.63 letters (95% CI -0.26 to 1.52, P=0.17) at 12 months. However, significant improvements were found in mean CRT after switching, with reductions of -61.90µm (95% CI -77.10 to -46.80, P<0.001) at 6 months and -50.00µm (95% CI -63.20 to -36.80, P<0.001) at 12 months. Thus, switching to aflibercept in the setting of treatment-resistant nAMD with bevacizumab and/or ranibizumab can be a reasonable option to consider.

Page | 7 of 10 ∞ Practice Guidelines and Position Statements

The AAO updated their Age-Related Macular Degeneration Preferred Practice Pattern in October 2019. For the treatment of nAMD, VEGF inhibitors are considered to be first-line therapy due to improvements in visual outcomes observed in clinical trials. The AAO does not offer a recommendation on the choice of agent, stating that the choice should be individually tailored based on patient and physician discussions. Pegaptanib does not improve visual activity and is rarely used in current clinical practice. Other treatment options include photodynamic therapy, thermal laser photocoagulation, surgery, and radiation therapy.

References

1. Flaxel CJ, Adelman RA, Bailey ST, et al. Age-Related Macular Degeneration Preferred Practice Pattern®. Ophthalmology. 2020; 127(1):P1-P65.

2. Ohji M, Takahashi K, Okada AA, et al. Efficacy and Safety of Intravitreal Aflibercept Treat-and-Extend Regimens in Exudative Age-Related Macular Degeneration: 52- and 96-Week Findings from ALTAIR : A Randomized Controlled Trial. Adv Ther. 2020;37(3):1173-1187.

3. Schmidt-Erfurth U, Kaiser PK, Korobelnik J-F, et al. Intravitreal aflibercept injection for neovascular age-related macular degeneration: ninety-six-week results of the VIEW studies. Ophthalmology. 2014;121(1):193-201.

4. Lass JH, Benetz BA, Menegay HJ, et al. Effects of Repeated Intravitreal Aflibercept Injection on the Corneal Endothelium in Patients With Age-Related Macular Degeneration: Outcomes From the RE-VIEW Study. Cornea. 2018;37(5):596-601.

5. Khurana RN, Rahimy E, Joseph WA, et al. Extended (Every 12 Weeks or Longer) Dosing Interval With Intravitreal Aflibercept and Ranibizumab in Neovascular Age-Related Macular Degeneration: Post Hoc Analysis of VIEW Trials. Am J Ophthalmol. 2019;200:161-168.

6. Kodjikian L, Souied EH, Mimoun G, et al. Ranibizumab versus Bevacizumab for Neovascular Age-related Macular Degeneration: Results from the GEFAL Noninferiority Randomized Trial. Ophthalmology. 2013;120(11):2300-2309.

7. CATT Research Group, Martin DF, Maguire MG, et al. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. 2011;364(20):1897-1908.

8. Dugel PU, Koh A, Ogura Y, et al. HAWK and HARRIER: Phase 3, Multicenter, Randomized, Double-Masked Trials of Brolucizumab for Neovascular Age-Related Macular Degeneration. Ophthalmology. 2020;127(1):72-84.

9. Novartis. Study of Efficacy and Safety of Brolucizumab vs. Aflibercept in Chinese Patients With Neovascular Age-Related Macular Degeneration. Available from: https://clinicaltrials.gov/ct2/show/NCT04047472. Accessed March 2, 2021.

10. Novartis. Study to Assess the Efficacy and Safety of Brolucizumab 6mg Compared to Aflibercept 2 mg in a Treat-to-control Regimen (TALON). Available from: https://clinicaltrials.gov/ct2/show/NCT04005352. Accessed March 2, 2021.

11. Friberg TR, Tolentino M, LEVEL Study Group, et al. Pegaptanib sodium as maintenance therapy in neovascular age-related macular degeneration: the LEVEL study. Br J Ophthalmol. 2010;94(12):1611-1617.

12. VEGF Inhibition Study in Ocular Neovascularization (V.I.S.I.O.N.) Clinical Trial Group, Chakravarthy U, Adamis AP, et al. Year 2 efficacy results of 2 randomized controlled clinical trials of pegaptanib for neovascular age-related macular degeneration. Ophthalmology. 2006;113(9):1508.e1-e25.

Page | 8 of 10 ∞ 13. Holz FG, Figueroa MS, Bandello F, et al. Ranibizumab treatment in treatment-naïve neovascular age-related macular degeneration: Results From LUMINOUS, a Global Real-World Study. Retina. November 2019. doi:10.1097/IAE.0000000000002670.

14. Ho AC, Busbee BG, Regillo CD, et al. Twenty-four-month efficacy and safety of 0.5 mg or 2.0 mg ranibizumab in patients with subfoveal neovascular age-related macular degeneration. Ophthalmology. 2014;121(11):2181-2192.

15. Feltgen N, Bertelmann T, Bretag M, et al. Efficacy and safety of a fixed bimonthly ranibizumab treatment regimen in eyes with neovascular age-related macular degeneration: results from the RABIMO trial. Graefes Arch Clin Exp Ophthalmol. 2017;255(5):923-934.

16. Silva R, Berta A, Larsen M, et al. Treat-and-Extend versus Monthly Regimen in Neovascular Age-Related Macular Degeneration: Results with Ranibizumab from the TREND Study. Ophthalmology. 2018;125(1):57-65.

17. Solomon SD, Lindsley K, Vedula SS, Krzystolik MG, Hawkins BS. Anti-vascular endothelial growth factor for neovascular age- related macular degeneration. Cochrane Database Syst Rev. 2019;3:CD005139.

18. Spooner K, Hong T, Wijeyakumar W, Chang AA. Switching to aflibercept among patients with treatment-resistant neovascular age-related macular degeneration: a systematic review with meta-analysis. Clin Ophthalmol. 2017;11:161-177.

19. Hernandez L, Lanitis T, Cele C, Toro-Diaz H, Gibson A, Kuznik A. Intravitreal Aflibercept Versus Ranibizumab for Wet Age- Related Macular Degeneration: A Cost-Effectiveness Analysis. J Manag Care Spec Pharm. 2018;24(7):608-616.

20. van Asten F, Michels CTJ, Hoyng CB, et al. The cost-effectiveness of bevacizumab, ranibizumab and aflibercept for the treatment of age-related macular degeneration-A cost-effectiveness analysis from a societal perspective. PLoS One. 2018;13(5):e0197670.

21. Nunes RP, Hirai FE, Rodrigues EB, Farah ME. Cost-effectiveness of Anti-VEGF treatments for age-related macular degeneration: a Brazilian perspective. Arq Bras Oftalmol. 2020;83(1):48-54.

22. Mitchell P, Liew G, Gopinath B, Wong TY. Age-related macular degeneration. Lancet. 2018;392(10153):1147-1159.

23. Singerman LJ, Masonson H, Patel M, et al. Pegaptanib sodium for neovascular age-related macular degeneration: third-year safety results of the VEGF Inhibition Study in Ocular Neovascularisation (VISION) trial. Br J Ophthalmol. 2008;92(12):1606-1611.

24. Wong, RV. Retina Specialists Warnings of Beovu. Retina Eye Doctor. Available from: https://retinaeyedoctor.com/2020/03/retina-specialists-warnings-of-beovu/. Accessed March 2, 2021.

25. Goldberg RA, Flynn HW Jr, Miller D, Gonzalez S, Isom RF. Streptococcus endophthalmitis outbreak after intravitreal injection of bevacizumab: one-year outcomes and investigative results. Ophthalmology. 2013; 120(7):1448-1453.

26. Bavinger JC, Yu Y, VanderBeek BL. Comparative risk of endophthalmitis after intravitreal injection with bevacizumab, aflibercept, and ranibizumab. Retina. 2019;39(10):2004-2011.

History

Date Comments 12/01/20 New policy, approved November 10, 2020, effective for dates of service on or after March 3, 2021, following 90-day provider notification. Includes Beovu (brolucizumab- dbll) for AMD; Eylea (aflibercept) for AMD, RVO, DME, and DR; Lucentis (ranibizumab) for AMD, RVO, DME, DR, and mCNV; and Macugen (pegaptanib) for AMD. HCPCS codes J0178, J0179, J2503 and J2778 are listed.

Page | 9 of 10 ∞ 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.

Page | 10 of 10 ∞

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Benachrichtigung enthält unter Umständen wichtige Informationen You can also file a civil rights complaint with the U.S. Department of Health bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera and Human Services, Office for Civil Rights, electronically through the Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Office for Civil Rights Complaint Portal, available at Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten U.S. Department of Health and Human Services zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in 200 Independence Avenue SW, Room 509F, HHH Building Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD) (TTY: 800-842-5357). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Hmoob (Hmong):

Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum Getting Help in Other Languages tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue This Notice has Important Information. This notice may have important Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv information about your application or coverage through Premera Blue no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub Cross. There may be key dates in this notice. You may need to take action dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj by certain deadlines to keep your health coverage or help with costs. You yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob have the right to get this information and help in your language at no cost. ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau Call 800-722-1471 (TTY: 800-842-5357). ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357). አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Iloko (Ilocano): Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion

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).