MEDICAL POLICY – 2.01.71 Nonpharmacologic Treatment of

BCBSA Ref. Policy: 2.01.71 Effective Date: Mar. 1, 2021 RELATED MEDICAL POLICIES: Last Revised: Feb. 2, 2021 10.01.514 Cosmetic and Reconstructive Services Replaces: 2.01.519

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POLICY CRITERIA | CODING | RELATED INFORMATION EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Rosacea is a long-lasting skin condition that affects adults. It usually affects more women than men. And while it can affect anyone, it usually occurs more frequently in people with fair skin. Typically, rosacea affects adults between the ages of 20 and 60. It often creates redness on the cheeks, nose, chin, or forehead. It can also affect the neck, chest, scalp, or ears. The redness tends to become more persistent over time, with little blood vessels appearing. Bumps and pimples may also develop. In some people, the nose becomes swollen or bumpy due to extra tissue. (This is known as rhinophyma.) While rosacea can’t be cured, medication (pharmacologic treatment) is effective in controlling symptoms. Other treatments, such as laser or light therapy or removing the top layers of the skin (dermabrasion), have been tried. These types of rosacea treatments are investigational (unproven). Published medical studies do not conclusively prove that they work as well as or better than using medication. More and longer studies are needed.

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 Investigational Nonpharmacologic Nonpharmacologic treatment of rosacea, including but not treatment of rosacea limited to laser and light therapy, dermabrasion, chemical peels, surgical debulking, and electrosurgery, is considered investigational.

Coding

Code Description CPT 17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq. cm

17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq. cm

17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq. cm

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

N/A

Evidence Review

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Description

Rosacea is a chronic, inflammatory skin condition without a known cure; the goal of treatment is symptom management. Nonpharmacologic treatments, including laser and light therapy as well as dermabrasion, which are the focus of this policy, are proposed for patients who do not want to use or are unresponsive to pharmacologic therapy.

Background

Rosacea

Rosacea is characterized by episodic erythema, edema, papules, and pustules that occur primarily on the face but may also be present on the scalp, ears, neck, chest, and back. On occasion, rosacea may affect the eyes. Patients with rosacea tend to flush or blush easily. Because rosacea causes facial swelling and redness, it is easily confused with other skin conditions, such as , skin allergy, and .

Rosacea mostly affects adults with fair skin between the ages of 20 and 60 years and is more common in women, but often most severe in men. Rosacea is not life-threatening, but if not treated, may lead to persistent erythema, telangiectasias, and rhinophyma (hyperplasia and nodular swelling and congestion of the skin of the nose). The etiology and pathogenesis of rosacea are unknown but may result from both genetic and environmental factors. Some theories on the causes of rosacea include blood vessel disorders, chronic Helicobacter pylori infection, Demodex folliculorum (mites), and immune system disorders.

While the clinical manifestations of rosacea do not usually impact the physical health status of the patient, psychological consequences from the most visually apparent symptoms (ie, erythema, papules, pustules, telangiectasias) that may impact the quality of life. Rhinophyma, an end-stage of chronic acne, has been associated with obstruction of nasal passages and basal cell carcinoma in rare, severe cases. The probability of developing nasal obstruction or basal or squamous cell carcinoma with rosacea is not sufficient to warrant preventive removal of rhinophymatous tissue.

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Treatment

Rosacea treatment can be effective in relieving signs and symptoms. Treatment may include oral and topical antibiotics, isotretinoin, β-blockers, clonidine, and anti-inflammatories. Patients are also instructed on various self-care measures such as avoiding skin irritants and dietary items thought to exacerbate acute flare-ups.

Nonpharmacologic therapy has also been tried in patients who cannot tolerate or do not want to use pharmacologic treatments. To reduce visible blood vessels, treat rhinophyma, reduce redness, and improve appearance, various techniques such as laser and light therapy, dermabrasion, chemical peels, surgical debulking, and electrosurgery have been used. Various lasers used include low-powered electrical devices and vascular light lasers to remove telangiectasias, co2 lasers to remove unwanted tissue from rhinophyma and reshape the nose, and intense pulsed lights (IPL) that generate multiple wavelengths to treat a broader spectrum of tissue.

Summary of Evidence

For individuals with rosacea who receive nonpharmacologic treatment (eg, laser therapy, light therapy, dermabrasion), the evidence includes systematic reviews and several small randomized, split-face design trials. The relevant outcomes are symptoms, change in disease status, and treatment-related morbidity. The systematic reviews reported favorable effects on erythema and telangiectasia with several laser types, including IPL, pulsed dye lasers, and Nd:YAG lasers. However, the systematic reviews did not pool results from individual studies and the studies differed in the specific lasers being compared. Overall, the systematic review results were insufficient to establish whether any laser type is more effective and safe than others. The randomized controlled trials evaluated laser and light therapy. No trials assessing other nonpharmacologic treatments were identified. None of the randomized controlled trials included a comparison group of patients receiving a placebo or pharmacologic treatment; therefore, these trials do not offer evidence on the efficacy of laser or light treatment compared with alternative treatments. There is a need for randomized controlled trials that compare nonpharmacologic treatments with placebo controls and with pharmacologic treatments. The evidence is insufficient to determine the effects of the technology on health outcomes.

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Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 1.

Table 1. Summary of Key Trials

NCT No. Trial Name Planned Completion Enrollment Date Ongoing NCT04153188a Pilot Study to Evaluate Vbeam® Prima Pulsed Dye Laser 60 July 2022 (PDL) Treatment and RHOFADE® (Oxymetazoline HCL, (ongoing) 1% Cream) for Erythematotelangiectatic Rosacea

Unpublished NCT03194698 Efficacy of Intense Pulsed Light Treatment of Dry Eye and 20 Dec 2018 Ocular Rosacea (completed)

NCT: national clinical trial a Denotes industry-sponsored or cosponsored trial

Practice Guidelines and Position Statements

American Acne and Rosacea Society

In 2014, the American Acne and Rosacea Society issued consensus recommendations on the management of rosacea.23 The Society stated that lasers and IPL devices could improve certain clinical manifestations of rosacea that have not responded to medical therapy. The recommendations indicated that these therapies would have to be repeated intermittently to sustain improvement.

In 2016, the American Acne and Rosacea Society issued updated consensus recommendations on the management of rosacea.24 The update focused on how medical and device therapies are used--whether concurrently or in a staggered fashion--noting that there is a lack of evidence to justify either use. The Society's consensus recommendation on rosacea management correlated with clinical manifestations observed at the time of presentation are summarized in Table 2.

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Table 2. Recommendations on Use of Lasers and Intensely Pulse Light Devices for the Management of Rosacea

Condition Recommendation Gradea Persistent central facial IPL, potassium titanyl phosphate crystal laser, or pulsed-dye laser B erythema without papulopustular lesions

Diffuse central facial “While the data on the use of IPL, potassium titanyl phosphate or NR erythema with pulsed-dye laser are limited for papulopustular lesions, these papulopustular lesions options are useful to treat erythema”

Granulomatous rosacea Intense pulsed-dye laser C

“No current standard of treatment; limited data based on case reports”

Phymatous Rosacea “Surgical therapy for fully developed phymatous changed C (carbon dioxide laser, erbium-doped [YAG] laser, electrosurgery, dermabrasion)”

“Treatment selection dependent on stage of development (early or fibrotic) and extent of inflammation (active or burnt out)”

IPL: intense pulsed light, YAG: yttrium aluminum garnet; NR: not reported. a Grade A: Criteria not described in recommendation; Grade B: Systematic review/meta-analysis of lower-quality clinical trials or studies with limitations and inconsistent findings; lower-quality clinical trial; Grade C: Consensus guidelines; usual practice, expert opinion, case series—limited trial data

American Academy of Dermatology

In 2017, the American Academy of Dermatology (AAD) released online guidance for treatment and management of rosacea.25 The AAD encouraged patients to identify their triggers to minimize symptoms, including protection from exposure to the sun, heat, stress, alcohol, and spicy foods. The AAD indicated that laser or light therapy may be used to reduce redness and that laser resurfacing may be used to remove thickening skin. The AAD also stated that “researchers continue to study how lasers and light treatments can treat rosacea. As we learn more, these devices may play a bigger role in treating rosacea.”

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Rosacea Consensus Panel

In 2017, the Rosacea Consensus panel, comprised of international experts including representatives from the United States, published recommendations for rosacea treatment.26 The panel agreed that treatments should be based on phenotype. Intense pulsed light and pulsed dye laser were recommended for persistent erythema, but not for transient erythema. Intense pulsed light and lasers were also recommended for telangiectasia rosacea.

The panel updated their recommendations on rosacea treatment in 2019, agreeing that lasers were recommended for persistent centrofacial erythema. They also noted that “use of IPL and vascular lasers in darker skin phototypes requires consideration by a healthcare provider with experience…, as it can result in dyspigmentation.” The panel also acknowledged that combining treatments could benefit patients with more severe rosacea and multiple rosacea features; however, “there remains an ongoing need for more studies to support combination treatment use in rosacea.”

National Rosacea Society

In 2019, the National Rosacea Society Executive Committee published an expert consensus document on management options for rosacea.27This document endorses treatment goals of an Investigator Global Assessment score of 0 and normalization of skin tone and color due to the notable impact of rosacea on patient quality of life. Light devices are discussed as treatment options along with medications, , and lifestyle interventions. Based on weak evidence, IPL, pulsed dye lasers, and potassium titanyl phosphate lasers are listed as moderately effective treatment options for persistent erythema, particularly due to telangiectasia. Both IPL and potassium titanyl phosphate are described as having at least some efficacy for flushing. Nonpharmacologic interventions that are listed as more highly effective treatment options for non-inflamed phymas (based on weak evidence) include carbon dioxide lasers, erbium lasers, cold steel, electrosurgery, and radiofrequency; these same interventions are listed for use in combination with other treatment modalities for inflammatory phymas. Carbon dioxide lasers, erbium lasers, cold steel, electrosurgery, and radiofrequency carry a risk of post-inflammatory and should only be provided by appropriately trained individuals.

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National Institutes for Health and Care Excellence

In 2017, the National Institutes for Health and Care Excellence published online pathways addressing skin damage and skin conditions.28 Pathways provide guidance on the use of topical agents to manage rosacea. There are no pathways, guidance, or recommendations on nonpharmacologic treatments for rosacea.

Medicare National Coverage

There is no national coverage determination.

Regulatory Status

Several laser and light therapy systems have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process for various dermatologic indications, including rosacea. For example, rosacea is among the indications for:

• Vbeam laser system (Candela)

• Stellar M22™ laser system (Lumenis)Harmony® XL multi-application platform laser device (Alma Lasers, Israel)

• UV-300 Pulsed Light Therapy System (New Star Lasers)

• CoolTouch® PRIMA Pulsed Light Therapy System (New Star Lasers).

FDA product code: GEX.

References

1. van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for rosacea. Cochrane Database Syst Rev. Apr 28 2015; (4): CD003262. PMID 25919144

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2. van Zuuren EJ, Fedorowicz Z, Tan J, et al. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. Br J Dermatol. Jul 2019; 181(1): 65-79. PMID 30585305

3. Wat H, Wu DC, Rao J, et al. Application of intense pulsed light in the treatment of dermatologic disease: a systematic review. Dermatol Surg. Apr 2014; 40(4): 359-77. PMID 24495252

4. Mark KA, Sparacio RM, Voigt A, et al. Objective and quantitative improvement of rosacea-associated erythema after intense pulsed light treatment. Dermatol Surg. Jun 2003; 29(6): 600-4. PMID 12786702

5. Taub AF. Treatment of rosacea with intense pulsed light. J Drugs Dermatol. Jun 2003; 2(3): 254-9. PMID 12848109

6. Schroeter CA, Haaf-von Below S, Neumann HA. Effective treatment of rosacea using intense pulsed light systems. Dermatol Surg. Oct 2005; 31(10): 1285-9. PMID 16188180

7. Karsai S, Roos S, Raulin C. Treatment of facial telangiectasia using a dual-wavelength laser system (595 and 1,064 nm): a randomized controlled trial with blinded response evaluation. Dermatol Surg. May 2008; 34(5): 702-8. PMID 18318728

8. Papageorgiou P, Clayton W, Norwood S, et al. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. Sep 2008; 159(3): 628-32. PMID 18565174

9. Neuhaus IM, Zane LT, Tope WD. Comparative efficacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea. Dermatol Surg. Jun 2009; 35(6): 920-8. PMID 19397667

10. Lane JE, Khachemoune A. Use of intense pulsed light to treat refractory granulomatous rosacea. Dermatol Surg. Apr 2010; 36(4): 571-3. PMID 20402938

11. Nymann P, Hedelund L, Haedersdal M. Long-pulsed dye laser vs. intense pulsed light for the treatment of facial telangiectasias: a randomized controlled trial. J Eur Acad Dermatol Venereol. Feb 2010; 24(2): 143-6. PMID 20205349

12. Fabi S, Peterson J, Goldman M. Combination 15% azelaic acid gel and intense pulse light therapy for mild to moderate rosacea. Lasers Surg Med 2011;43:9689.

13. Kassir R, Kolluru A, Kassir M. Intense pulsed light for the treatment of rosacea and telangiectasias. J Cosmet Laser Ther. Oct 2011; 13(5): 216-22. PMID 21848421

14. Kim TG, Roh HJ, Cho SB, et al. Enhancing effect of pretreatment with topical niacin in the treatment of rosacea-associated erythema by 585-nm pulsed dye laser in Koreans: a randomized, prospective, split-face trial. Br J Dermatol. Mar 2011; 164(3): 573-9. PMID 21143465

15. Huang YE, Li XL, Li TJ. [Clinical research of topical tacrolimus ointment combined with 585 nm pulsed dye laser in the treatment of rosacea]. J Clinical Dermatol 2012; 41:3089.

16. Alam M, Voravutinon N, Warycha M, et al. Comparative effectiveness of nonpurpuragenic 595-nm pulsed dye laser and microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser for treatment of diffuse facial erythema: A double-blind randomized controlled trial. J Am Acad Dermatol. Sep 2013; 69(3): 438-43. PMID 23688651

17. Friedmann DP, Fabi SG, Goldman MP, Guiha I. The effect of multiple sequential light sources to activate aminolevulinic acid in the treatment of acne vulgaris. Lasers Surg Med 2013;45:57.

18. Seo HM, Kim JI, Kim HS, et al. Prospective Comparison of Dual Wavelength Long-Pulsed 755-nm Alexandrite/1,064-nm Neodymium:Yttrium-Aluminum-Garnet Laser versus 585-nm Pulsed Dye Laser Treatment for Rosacea. Ann Dermatol. Oct 2016; 28(5): 607-614. PMID 27746641

19. Maxwell EL, Ellis DA, Manis H. Acne rosacea: effectiveness of 532 nm laser on the cosmetic appearance of the skin. J Otolaryngol Head Neck Surg. Jun 2010; 39(3): 292-6. PMID 20470675

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20. Campos MA, Sousa AC, Varela P, et al. Comparative effectiveness of purpuragenic 595 nm pulsed dye laser versus sequential emission of 595 nm pulsed dye laser and 1,064 nm Nd:YAG laser: a double-blind randomized controlled study. Acta Dermatovenerol Alp Pannonica Adriat. Mar 2019; 28(1): 1-5. PMID 30901061

21. Kim BY, Moon HR, Ryu HJ. Comparative efficacy of short-pulsed intense pulsed light and pulsed dye laser to treat rosacea. J Cosmet Laser Ther. Aug 2019; 21(5): 291-296. PMID 30285506

22. Tirico MCCP, Jensen D, Green C, et al. Short pulse intense pulsed light versus pulsed dye laser for the treatment of facial redness. J Cosmet Laser Ther. Feb 17 2020; 22(2): 60-64. PMID 32041440

23. Tanghetti E, Del Rosso JQ, Thiboutot D, et al. Consensus recommendations from the American acne rosacea society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. Feb 2014; 93(2): 71-6. PMID 24605343

24. Del Rosso JQ, Tanghetti E, Webster G, et al. Update on the Management of Rosacea from the American Acne Rosacea Society (AARS). J Clin Aesthet Dermatol. Jun 2019; 12(6): 17-24. PMID 31360284

25. American Academy of Dermatology. Lasers and lights: How well do they treat rosacea? 2017; https://www.aad.org/rosacea- lasers-lights. Accessed February 3, 2021.

26. Schaller M, Almeida LMC, Bewley A, et al. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. Br J Dermatol. May 2020; 182(5): 1269-1276. PMID 31392722

27. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. Jun 2020; 82(6): 1501-1510. PMID 32035944

28. National Institutes for Health and Care Excellence (NICE). Skin conditions overview. 2017; https://pathways.nice.org.uk/pathways/skin-conditions. Accessed February 3, 2021.

History

Date Comments 03/01/18 Policy reinstated, approved February 13, 2018, effective June 1, 2018. This policy was previously deleted, but now replaces policy 2.01.519. Nonpharmacologic treatment of rosacea is considered investigational.

06/01/18 Minor update; removed note and link to previous policy 2.01.519 which has been deleted.

03/01/19 Annual Review, approved February 5, 2019. Policy updated with literature review through October 2018; references 11 added. Policy statement unchanged.

03/01/20 Annual Review, approved February 4, 2020. Policy updated with literature review through October 2019; references added. Policy statement unchanged.

03/01/21 Annual Review, approved February 2, 2021. Policy updated with literature review through October 21, 2020; referenced added. Policy statement unchanged.

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

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