PHARMACY / MEDICAL POLICY – 5.01.592 Phosphoinositide 3-kinase (PI3K) Inhibitors

Effective Date: May 1, 2021 RELATED MEDICAL POLICIES: Last Revised: April 13, 2021 None Replaces: N/A

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

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Introduction

Phosphoinositide 3-kinase inhibitors (PI3K inhibitors) block one or more enzymes, which are part of an important signaling pathway inside cells, essentially working to turn the cell growth to the “off” position. This policy describes when this specific form of chemotherapy 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 Aliqopa™ (copanlisib) (IV Aliqopa™ (copanlisib) or Copiktra™ (duvelisib) may be infusion) considered medically necessary for patients with Chronic Copiktra™ (duvelisib) (oral) Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) or (FL) when the following criteria are met: Drug Medical Necessity • Patient is at least 18 years of age, AND • Patient has had at least two prior systemic therapies Ukoniq™ () Ukoniq™ (umbralisib) may be considered medically necessary (oral) for the treatment of adult patients with ANY of the following: • Relapsed or refractory marginal zone lymphoma (MZL) who have received at least one prior anti-CD20 (eg, ) based regimen • Relapsed or refractory follicular lymphoma (FL) who have received at least three prior lines of systemic therapy AND • For both indications listed above the dose is limited to 800 mg per day Zydelig® () (oral) Zydelig® (idelalisib) may be considered medically necessary for the treatment of patients with ANY of the following: • Relapsed chronic lymphocytic leukemia (CLL), in combination with rituximab, in patients for whom rituximab alone would be considered appropriate therapy due to other co-morbidities • Relapsed follicular B-cell non-Hodgkin lymphoma (FL) in patients who have received at least two prior systemic therapies • Relapsed small lymphocytic lymphoma (SLL) in patients who have received at least two prior systemic therapies AND • For all indications listed above the dose is limited to 300 mg per day (taken as 150 mg twice daily)

Note: Zydelig is not indicated and is not recommended for first-line treatment of any patient.

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

Page | 2 of 11 ∞ Length of Approval Approval Criteria Initial authorization Oral drugs listed in policy may be approved up to 3 months.

Injectable drugs listed in policy may be approved up to 6 months. Re-authorization criteria Future re-authorization of oral and injectable drugs 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, physical evaluation and medication history

Coding

Code Description HCPC J9057 Injection, copanlisib (Aliqopa™), 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

Consideration of Age

Age limits specified in this policy are determined according to U.S. Food and Drug Administration (FDA) -approved indications, where applicable.

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Benefit Application

The drugs in this policy that are administered orally (Copiktra™, Ukoniq™, and Zydelig®) are managed through the Pharmacy benefit. Drugs administered via IV infusion (Aliqopa™) are managed through the Medical benefit.

Evidence Review

Description

Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Lymphoma (SLL) and Follicular Lymphoma (FL)

CLL and SLL are different manifestations of the same lymphocytic malignancy and are subtypes of Non-Hodgkin Lymphoma (NHL). The primary difference between these conditions is that a majority of leukemic B-cells circulate in the blood in CLL, whereas they are found in lymphoid tissue in SLL. FL is another B-cell lymphoproliferative disorder and subtype of NHL.

Disease Burden

Approximately 7% of newly diagnosed NHL cases are CLL/SLL. In the US in 2018, the incidence of CLL is estimated to be 21,000 and approximately 4500 people will die of the disease. CLL is the most prevalent adult leukemia in Western countries. CLL is mainly diagnosed in older adults (median 72 years of age). Between 1998 and 2011, FL comprised 17% of all NHL diagnosed in the US. It is the second most common form of NHL and the most common form of indolent NHL.

Pathophysiology

CLL/SLL is characterized by a progressive accumulation of mature lymphocytes in the blood, bone marrow, and lymphoid tissues. These conditions typically proceed through a couple of different phases consisting of an early indolent phase where cells are small in size, proliferation

Page | 4 of 11 ∞ is low, and there is prolonged cell survival and a transformation phase characterized by an increase in large immature cells and extramedullary proliferation. Unfavorable prognostic indicators include unmutated immunoglobulin heavy-chain variable (IGHV) status, TP53 mutation, the presence of cytogenic abnormalities (del[13q] or del[11q]), higher levels of flow- cytometry based prognostic markers (CD38, CD49d, and ZAP-70), and serum markers (eg, thymidine kinase and beta-2 microglobulin).

Patients with low-grade indolent disease without signs or symptoms for initiating treatment usually receive supportive care and watchful waiting as therapy, given active treatment has not been shown to prolong survival. Signs and symptoms for initiating active treatment include severe fatigue, weight loss, night sweats, fever (without ), progressive bulky disease (enlarged spleen and/or lymph nodes), progressive anemia or thrombocytopenia, autoimmune anemia, thrombocytopenia unresponsive to corticosteroids, and threatened end-organ function.

FL is caused by a translocation between chromosome 14 and 18 that results in overexpression of the bcl-2 gene. This gene produces a protein that prevents apoptosis. Consequently, cells that overexpress the bcl-2 protein are basically immortal. Other translocations may also be involved. FL tumors are composed of centrocytes and centroblasts, and the volume of these cell types determines World Health Organization morphological grade.

Patients with asymptomatic disease usually receive supportive care and watchful waiting as therapy. When patients are symptomatic active treatment is initiated, with consideration to age, stage, and International Prognostic Index score.

Treatment Alternatives

National Comprehensive Cancer Network (NCCN) Recommended Preferred First-line Regimens Include:

R/R CLL/SLL: patients w/o del(17p)/TP53 mutation – acalabrutinib ± obinutuzumab; ibrutinib; + obinutuzumab

R/R CLL/SLL: patients w/ del(17p)/TP53 mutation - acalabrutinib ± obinutuzumab; ibrutinib; venetoclax + obinutuzumab

R/R FLL (grade 1-2): or CHOP or CVP + obinutuzumab or rituximab; lenalidomide + rituximab; elderly patients or infirm – rituximab

Page | 5 of 11 ∞ PI3K Inhibitors

Copanlisib, duvelisib, idelalisib, and umbralisib are oral selective small molecule inhibitors of one or more of the phosphoinositide 3-kinase enzymes, which are part of the PI3K/AKT/mTOR pathway, an important signaling pathway for many cellular functions such as growth control, metabolism and translation initiation. Within this pathway there are many components, inhibition of which may result in tumor suppression.

There are a number of different classes and isoforms of PI3Ks. Class 1 PI3Ks have a catalytic subunit known as p110, with four types (isoforms) – p110 alpha, p110 beta, p110 gamma and p110 delta. The inhibitors being studied inhibit one or more isoforms of the class I PI3Ks. They are being actively investigated for treatment of various cancers. PI3K signaling is believed to play a role in the proliferation of malignant B- and T-cells and in the formation and maintenance of a supportive tumor microenvironment. The currently approved agents have the following target profiles:

• Copanlisib: targets alpha and delta

• Duvalisib: targets gamma and delta

• Idelalisib: targets delta

• Umbralisib: targets delta

Summary of Evidence

Aliqopa™ (copanlisib)

The efficacy of Aliqopa™ (copanlisib) was evaluated in a single-arm, multicenter, phase 2 , CHRONOS-1 in a total of 142 subjects, which included 104 subjects with follicular B-cell non-Hodgkin lymphoma who had relapsed disease following at least two prior treatments. Patients must have received rituximab and an alkylating agent. The most common prior systemic therapies were chemotherapy in combination with anti-CD20 immunotherapy (89%), chemotherapy alone (41%), and anti-CD20 immunotherapy alone (37%). In CHRONOS-1, 34% of patients received two prior lines of therapy and 36% received three prior lines of therapy.

One hundred forty-two patients received 60 mg Aliqopa; 130 patients received fixed dose 60 mg Aliqopa and 12 patients received 0.8 mg/kg equivalent Aliqopa administered as a 1-hour intravenous infusion on Days 1, 8, and 15 of a 28-day treatment cycle on an intermittent schedule (three weeks on and one week off). Treatment continued until disease progression or

Page | 6 of 11 ∞ unacceptable toxicity. Tumor response was assessed according to the International Working Group response criteria for malignant lymphoma. Efficacy based on overall response rate (ORR) was assessed by an Independent Review Committee. Overall Response Rate (ORR) was 59% (61 patients, 95% CI (49, 68). Of these, 15 patients achieved a Complete Response. Median Duration of Response was 12.2 months (range 0+, 22.6 months).

Copiktra™ (duvelisib)

One moderate quality phase 3, randomized open-label, active-controlled clinical trial (DUO) demonstrates statistically significant incremental improvements in progression-free survival (PFS) of 3.4 months, objective response rate (ORR) of 28.5%, and lymph node response rate (LNRR) of 69% with duvelisib vs ofatumumab in patients with R/R CLL or SLL. One fair quality phase 2, open-label, single arm study (DYNAMO) of duvelisib monotherapy in adults with double-refractory iNHL showed an overall ORR of 46%, a median DoR of 9.9 months, a LNRR of 83%, a median PFS of 8.4 months, and a median OS of 18.4 months. Response appeared better in patients with SLL than in those with FL. Other potentially supportive studies of duvelisib monotherapy in patients with CLL or iNHL and off-label studies in patients with R/R peripheral T-cell lymphoma (PTCL) and for use in combination with chemoimmunotherapy are ongoing.

Ukoniq™ (umbralisib)

The efficacy of umbralisib was evaluated in a single-arm cohort of Study UTX-TGR-205 (NCT02793583), an open-label, multi-center, multi-cohort trial. Patients with MZL were required to have received at least one prior therapy, including an anti-CD20 containing regimen. The trial excluded patients with prior exposure to a PI3K inhibitor. Patients received umbralisib 800 mg orally once daily until disease progression or unacceptable toxicity. A total of 69 patients with MZL [extranodal (N=38), nodal (N=20), and splenic (N=11)] were enrolled in this cohort. Patients had a median number of prior lines of therapy of 2 (range: 1 to 6), with 26% being refractory to their last therapy. Efficacy was based on overall response rate as assessed by an Independent Review Committee (IRC) using criteria adopted from the International Working Group criteria for malignant lymphoma. The median follow-up time was 20.3 months (range: 15.0 to 28.7 months). The median time to response was 2.8 months (range: 1.8 to 21.2 months). Overall response rates were 44.7%, 60.0%, and 45.5% for the 3 MZL sub-types (extranodal, nodal, and splenic, respectively).

Page | 7 of 11 ∞ The efficacy of umbralisib was evaluated in a single-arm cohort of Study UTX-TGR-205, an open- label, multi-center, multi-cohort trial (NCT02793583). Patients with relapsed or refractory FL were required to have received at least two prior systemic therapies, including an anti-CD20 monoclonal antibody and an alkylating agent. The trial excluded patients with Grade 3b FL, large cell transformation, prior allogeneic transplant, history of CNS lymphoma, and prior exposure to a PI3K inhibitor. Patients received umbralisib 800 mg orally once daily until disease progression or unacceptable toxicity. A total of 117 patients with FL were enrolled in this cohort. Patients had a median of 3 prior lines of therapy (range: 1 to 10), with 36% refractory to their last therapy. Efficacy was based on overall response rate as assessed by an IRC using criteria adopted from the International Working Group criteria for malignant lymphoma. The median follow-up time was 20.1 months (range: 13.5 to 29.6 months). The median time to response was 4.4 months (range: 2.2 to 15.5 months).

Zydelig® (idelalisib)

Zydelig® (idelalisib) is the first selective and reversible inhibitor of PI3K to receive FDA approval. It was approved on the basis of one multicenter, randomized, double-blind, Phase 3 study. The patients were randomly assigned to receive rituximab with either idelalisib or placebo. The patients in the placebo group who had disease progression were able to crossover to receive idelalisib. Patients in the idelalisib group who had disease progression could receive an increased dose.

The addition of idelalisib to rituximab therapy resulted in improved overall response rate (81% with idelalisib vs 13% with placebo). There were no complete responses. A higher proportion of patients with a reduction of lymphadenopathy of 50% or greater was observed with idelalisib (93% vs 4%). Improved progression-free survival (93% vs 46%) was also seen at 24 weeks with idelalisib; PFS median was not reached with idelalisib vs 5.5 months with placebo. (HR 0.15; 95% CI 0.08-0.28). Overall survival rate at 12 months was (92% vs 80%; HR 0.28; 95% CI 0.09-0.86).

Idelalisib for treatment of relapsed FL and SLL is shown in the DELTA study, which is an open- label, single arm, Phase 2 study. Phase 3 trials are ongoing and need to be assessed given the estimated primary completion date (December 2015) and estimated study completion date (April 2016) to establish whether there is an improvement in duration of response, and disease- related symptoms. In comparison, a phase 1b-2 multicenter study assessing ibrutinib as treatment for relapsed CLL in a similar population showed that at 26 months, the estimated progression-free survival rate was 75% and the rate of overall survival was 83%.

Page | 8 of 11 ∞ More than 90% of the patients were reported with having at least one adverse event. The common adverse events included pyrexia, fatigue, nausea, chills, and diarrhea. Serious adverse events included pneumonia, pyrexia, and febrile neutropenia. Adverse events leading to study- drug discontinuation were reported in 8%. Gastrointestinal and skin disorders lead to 6 discontinuations in the idelalisib group.

In March 2016, the FDA released a safety alert stating that 6 clinical trials studying first-line CLL and early-line iNHL have been terminated due to concerns of decreased overall survival and increased risk of serious adverse events (mostly including PCP pneumonia and CMV that could lead to sepsis and death). Health care authorities (FDA, Health Canada) reiterated that idelalisib is only indicated for relapsed CLL, relapsed SLL, and relapsed FL. NCCN CLL/SLL 1.2017 guidelines and NCCN NHL 3.2016 guidelines list idelalisib as a treatment option for these indications. It now carries a black box warning for “fatal and serious toxicities: hepatic, severe diarrhea, colitis, pneumonitis, infections, and intestinal perforation.”

2019 Update

Reviewed prescribing information for all drugs in policy. No new information was identified that would require changes to this policy.

2020 Update

Reviewed prescribing information for all drugs in policy. No new information was identified that would require changes to this policy.

2021 Update

Reviewed prescribing information for all drugs in policy. No new information was identified that would require changes to this policy for Aliqopa™ (copanlisib), Copiktra™ (duvelisib), and Zydelig® (idelalisib). Added coverage criteria for Ukoniq™ (umbralisib) for the treatment of marginal zone lymphoma (MZL) and follicular lymphoma (FL).

References

Page | 9 of 11 ∞

1. Neri LM1, Borgatti P, Tazzari PL, et al. The phosphoinositide 3-kinase/AKT1 pathway involvement in drug and all-trans-retinoic acid resistance of leukemia cells. Mol Cancer Res. 2003 Jan;1(3):234-46.

2. Wu M1, Akinleye A, Zhu X. Novel agents for chronic lymphocytic leukemia. J Hematol Oncol. 2013 May 16;6:36. doi: 10.1186/1756-8722-6-36.

3. Flinn I, Hillmen P, Montillo M, et al. Results of the phase 3 DUO™ study of duvelisib vs ofatumumab in re-lapsed/refractory CLL/SLL [oral presentation]. Presented at the 2017 American Society of Hematology Annual Meeting; December 9-12, 2017; Atlanta, GA, USA. Available at: https://www.verastem.com/wp-content/uploads/2018/03/Flinn-et-al-ASH-2017.pdf Accessed April 23, 2021.

4. Weaver DT, Sprott K, Pachter JA, et al. Duvelisib inhibition of chemokines in patients with CLL (DUO™) and iNHL (DYNAMO™) [poster]. Presented at the 2018 American Society of Clinical Oncology Annual Meeting; June 1-5, 2018; Chicago, IL, USA. Poster no. 161. Available at: http://www.verastem.com/wp-content/uploads/2018/06/Chemokine_ASCO-Poster-2018.pdf Accessed April 23, 2021.

5. Zinzani PL, Wagner-Johnston N, Miller C, et al. DYNAMO: a phase 2 study demonstrating the clinical activity of duvelisib in patients with double-refractory follicular lymphoma [abstract]. Hematologica. 2017;102(suppl 2):315.

6. Zinzani PL, Wagner-Johnston N, Miller C, et al. DYNAMO: the clinical activity of duvelisib in patients with double-refractory small lymphocytic lymphoma in a phase 2 study [abstract]. Hematologica. 2017;102(suppl 2):464-465.

7. Wierda WG, Zelenetz AD, Gordon LI, et al. NCCN guidelines insights: chronic lymphocytic leukemia/small lymphocytic leukemia, version 1.2017. J Natl Compr Canc Netw. 2017; 15:298-311.

8. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Chronic Lymphocytic Leukemia/Small Lymphocytic Leukemia, v3.2021. Available at: www.nccn.org Accessed April 23, 2021.

9. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: B-Cell Lymphomas, v3.2021. Available at: www.nccn.org Accessed April 2021.

10. Flinn IW, O’Brien S, Kahl B, et al. Duvelisib, a novel oral dual inhibitor of PI3K-δ,γ, is clinically active in advanced hematologic malignancies. Blood. 2018;131(8):877-887.

11. Furman, Richard R. "Idelalisib and Rituximab in Relapsed Chronic Lymphocytic Leukemia." New England Journal of Medicine 370.11 (2014): 1-11. PubMed. Web. 8 Aug. 2014. Available at: http://www.nejm.org.offcampus.lib.washington.edu/doi/full/10.1056/NEJMoa1315226 Accessed April 23, 2021.

12. Byrd, John C. "Journal of Clinical Oncology." Entering the Era of Targeted Therapy for Chronic Lymphocytic Leukemia: Impact on the Practicing Clinician. Journal of Clinical Oncology, 21 July 2014. Web. 13 Aug. 2014.

13. Gopal, Ajay K. "PI3Kδ Inhibition by Idelalisib in Patients with Relapsed ." New England Journal of Medicine 370 (2014): 1008-018. The New England Journal of Medicine. Web. 13 Aug. 2014. www.nejm.org.offcampus.lib.washington.edu/doi/full/10.1056/NEJMoa1314583. Accessed April 23, 2021.

14. Flinn IW, Hillmen P, Montillo M, et al. The phase 3 DUO trial: duvelisib versus ofatumumab in relapsed and refractory CLL/SLL. Blood. 2018 Oct 4. pii: blood-2018-05-850461. doi: 10.1182/blood-2018-05-850461. [Epub ahead of print]

15. Ali AY, Wu X, Eissa N, et al. Distinct roles for phosphoinositide 3-kinases γ and δ in malignant B cell migration. Leukemia. 2018 Sep;32(9):1958-1969. doi: 10.1038/s41375-018-0012-5. Epub 2018 Jan 31.

16. Zydelig Product Information. Gilead Sciences, Inc., Foster City, CA. Updated October 2020.

17. Aliqopa Product Information. Bayer HealthCare Pharmaceuticals Inc. Whippany, NJ. Updated November 2020.

18. Copiktra Product Information. Verastem, Inc. Needham, MA. Updated July 2019.

19. Ukoniq Product Information. TG Therapeutics, Inc., Edison, NJ. Updated February 2021.

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History

Date Comments 12/01/18 New policy approved November 13, 2018. Add to section. Aliqopa (copanlisib), Copiktra (duvelisib), or Zydelig (idelalisib) may be considered medically necessary when criteria are met. They are considered investigational for all other uses.

01/01/19 Coding update, added new HCPCS code J9057 (new code effective 1/1/19). Removed HCPCS code J9999.

01/01/20 Annual Review, approved December 10, 2019. No changes to policy statement.

08/01/20 Annual Review, approved July 23, 2020. Added a daily dose limit to Zydelig (idelalisib).

05/01/21 Annual Review, approved April 13, 2021. Added coverage criteria for Ukoniq (umbralisib) for the treatment of MZL and FL.

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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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).