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Mandatory Specialty Drug List

Mandatory Specialty Drug List

Mandatory Specialty Drug List

Depending on your pharmacy plan, drugs on this list may be required to be filled only at preferred, in‐ network, specialty pharmacies. This may be because: •Distribu on of the drug is restricted by the manufacturer •The drug requires paent educaon, provider coordinaon, or special handling

Specialty pharmacies provide additional care beyond standard retail pharmacies. This includes access to specialized: •Pharmacists •Reimbursement experts •Pa ent advocates

BRAND NAME GENERIC DRUG NME ABIRATERONE ABIRATERONE ACETATE ABRAXANE* ‐BOUND ACTEMRA ACTEMRA* TOCILIZUMAB ACTEMRA ACTPEN TOCILIZUMAB ACTHAR CORTICOTROPIN ACTIMMUNE " GAMMA‐1B,RECOMB." ADCETRIS* ADEMPAS RIOCIGUAT ADYNOVATE* "ANTIHEMO.FVIII,FULL LENGTH PEG" AFINITOR AFINITOR DISPERZ EVEROLIMUS AFSTYLA* "ANTIHEM.FVIII,SIN‐CHN,B‐DM TRU" ALDURAZYME* LARONIDASE ALECENSA HCL ALPHANATE* ANTIHEMOPHILIC FACTOR/VWF ALPHANINE SD* FACTOR IX ALPROLIX* "FACTOR IX REC, FC FUSION PROTN" AMBRISENTAN AMPYRA DALFAMPRIDINE APOKYN APOMORPHINE HCL ARALAST NP* ALPHA‐1‐PROTEINASE INHIBITOR ARANESP IN POLYSORBAT ARCALYST ARRANON* ARZERRA* ASCENIV* "IMMUNE GLOBULIN,GAMMA(IGG)SLRA" AUBAGIO AUSTEDO DEUTETRABENAZINE AVASTIN* AVONEX INTERFERON BETA‐1A/ALBUMIN AVONEX INTERFERON BETA‐1A AVONEX PEN INTERFERON BETA‐1A AVSOLA* ‐AXXQ * AZACITIDINE BAFIERTAM MONOMETHYL FUMARATE BEBULIN* "FACTOR IX CPLX(PCC)NO6,3FACTOR" BELRAPZO* HCL BENDAMUSTINE HCL* BENDAMUSTINE HCL BENDEKA* BENDAMUSTINE HCL BENEFIX* FACTOR IX HUMAN RECOMBINANT BENLYSTA* BENLYSTA* BELIMUMAB BEOVU* ‐DBLL BERINERT* C1 ESTERASE INHIBITOR BESPONSA* BETASERON INTERFERON BETA‐1B

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME BIVIGAM* IMMUN GLOB G(IGG)/GLY/IGA OV50 BOSENTAN BOSULIF BRAFTOVI BRONCHITOL MANNITOL CABOMETYX S‐MALATE CAPECITABINE CARBAGLU CAYSTON AZTREONAM LYSINE CERDELGA TARTRATE CEREZYME* CETROTIDE CETRORELIX ACETATE CHORIONIC GONADOTROPIN "CHORIONIC GONADOTROPIN, HUMAN" CIMZIA CINRYZE* C1 ESTERASE INHIBITOR COPAXONE COPEGUS RIBAVIRIN CORIFACT* FACTOR XIII COSENTYX (2 SYRINGES) COSENTYX PEN SECUKINUMAB COSENTYX PEN (2 PENS) SECUKINUMAB COSENTYX SYRINGE SECUKINUMAB COTELLIC FUMARATE CRYSVITA* ‐TWZA CUTAQUIG* IMMUN GLOB G(IGG)‐HIPP/MALTOSE CUVITRU* IMMUN GLOB G(IGG)/GLY/IGA OV50 CYRAMZA* CYTOGAM* CYTOMEGALOVIRUS IMMUNE GLOBULN DACOGEN* DALFAMPRIDINE ER DALFAMPRIDINE DARZALEX* DARZALEX FASPRO* DARATUMUMAB‐‐FIHJ DAURISMO MALEATE DECITABINE* DECITABINE DEFERASIROX DEFERASIROX DIMETHYL FUMARATE DOJOLVI DOPTELET MALEATE DROXIDOPA DROXIDOPA DUOPA* CARBIDOPA/LEVODOPA DUPIXENT PEN DUPIXENT SYRINGE DUPILUMAB DUROLANE* "HYALURONATE SODIUM, STABILIZED" DURYSTA* BIMATOPROST DYSPORT* ABOBOTULINUMTOXINA EGRIFTA* ACETATE EGRIFTA SV* TESAMORELIN ACETATE ELAPRASE* ELELYSO* ELOCTATE* "ANTIHEMOPH.FVIII REC,FC FUSION" EMFLAZA DEFLAZACORT EMPLICITI* ENBREL ENBREL MINI ETANERCEPT ENBREL SURECLICK ETANERCEPT ENDARI ENHERTU* FAM‐ DERUXTECN‐NXKI ENSPRYNG ‐MWGE ENTYVIO* EPCLUSA SOFOSBUVIR/VELPATASVIR

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME EPIDIOLEX CANNABIDIOL (CBD) EPOGEN EPOPROSTENOL SODIUM* EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM* EPOPROSTENOL SODIUM (GLYCINE) ERBITUX* ERIVEDGE ERLEADA APALUTAMIDE HCL ERLOTINIB HCL ESBRIET ESPEROCT* "FVIII REC,B‐DOM TRUNC PEG‐EXEI" EVENITY ‐AQQG EVENITY (2 SYRINGES) ROMOSOZUMAB‐AQQG EVEROLIMUS EVEROLIMUS EVRYSDI RISDIPLAM EXJADE DEFERASIROX EXTAVIA INTERFERON BETA‐1B EYLEA* FABRAZYME* AGALSIDASE BETA FARYDAK LACTATE FASENRA FASENRA PEN BENRALIZUMAB FEIBA NF* ANTI‐INHIBITOR COAGULANT COMP. FIRAZYR ACETATE FIRMAGON* DEGARELIX ACETATE FLOLAN* EPOPROSTENOL SODIUM (GLYCINE) FOLLISTIM AQ "FOLLITROPIN BETA,RECOMB" FOLOTYN* FORTEO GALAFOLD MIGALASTAT HCL GAMMAGARD LIQUID* IMMUN GLOB G(IGG)/GLY/IGA OV50 GAMMAGARD S‐D* IMMUN GLOB G/GLY/GLUC/IGA 0‐50 GAMMAKED* IMMUNE GLOBUL G/GLY/IGA AVG 46 GAMMAPLEX* IMMUN GLOB G(IGG)/GLY/IGA 0‐50 GAMMAPLEX* IMMUN GLOB G/SORB/GLY/IGA 0‐50 GAMUNEX‐C* IMMUNE GLOBUL G/GLY/IGA AVG 46 GANIRELIX ACETATE GANIRELIX ACETATE GATTEX GAZYVA* GEL‐ONE* "HYALURONATE SOD, CROSS‐LINKED" GENOTROPIN SOMATROPIN GILENYA HCL GILOTRIF DIMALEATE GIVLAARI* SODIUM GLASSIA* ALPHA‐1‐PROTEINASE INHIBITOR GLATIRAMER ACETATE GLATIRAMER ACETATE GLATOPA GLATIRAMER ACETATE GLEEVEC MESYLATE GONAL‐F "FOLLITROPIN ALFA, RECOMBINANT" GONAL‐F RFF "FOLLITROPIN ALFA, RECOMBINANT" GONAL‐F RFF REDI‐JECT "FOLLITROPIN ALFA, RECOMBINANT" HAEGARDA C1 ESTERASE INHIBITOR HALAVEN* MESYLATE HARVONI LEDIPASVIR/SOFOSBUVIR HEMLIBRA EMICIZUMAB‐KXWH HERCEPTIN* TRASTUZUMAB HERCEPTIN HYLECTA* TRASTUZUMAB‐HYALURONIDASE‐OYSK HERZUMA* TRASTUZUMAB‐PKRB HETLIOZ TASIMELTEON HETLIOZ LQ TASIMELTEON HIZENTRA* IMMUN GLOB G(IGG)/PRO/IGA 0‐50

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME HUMATE‐P* ANTIHEMOPHILIC FACTOR/VWF HUMATROPE SOMATROPIN HUMIRA HUMIRA PEDIATRIC CROHN'S ADALIMUMAB HUMIRA PEN ADALIMUMAB HUMIRA PEN CROHN'S‐UC‐HS ADALIMUMAB HUMIRA PEN PSOR‐UVEITS‐AD ADALIMUMAB HUMIRA(CF) ADALIMUMAB HUMIRA(CF) PEDIATRIC CROHNADALIMUMAB HUMIRA(CF) PEN ADALIMUMAB HUMIRA(CF) PEN CROHN'S‐UC‐ADALIMUMAB HUMIRA(CF) PEN PEDIATRIC UCADALIMUMAB HUMIRA(CF) PEN PSOR‐UV‐AD ADALIMUMAB HYCAMTIN HCL HYMOVIS* "HYALURONATE,MOD.,NON‐CROSSLINK" HYQVIA* "IGG/HYALURONIDASE,RECOMBINANT" IBRANCE IDELVION* "FACTOR IX RECOM,ALBUMIN FUSION" IDHIFA MESYLATE ILARIS* /PF ILUMYA* ‐ASMN ILUVIEN* FLUOCINOLONE ACETONIDE IMATINIB MESYLATE IMATINIB MESYLATE IMFINZI* INCRELEX INFLECTRA* INFLIXIMAB‐DYYB INLYTA INQOVI DECITABINE/CEDAZURIDINE INREBIC DIHYDROCHLORIDE INTRON A* "‐2B,RECOMB." IRESSA ISTODAX* IXEMPRA* IXINITY* "FACTOR IX HUMAN RECOMB,THR 148" JADENU DEFERASIROX JADENU SPRINKLE DEFERASIROX JAKAFI JEMPERLI* ‐GXLY JEVTANA* JIVI* "FVIII REC,B‐DOM DELET PEG‐AUCL" JUXTAPID LOMITAPIDE MESYLATE KADCYLA* ADO‐ KALBITOR* KALYDECO IVACAFTOR KANJINTI* TRASTUZUMAB‐ANNS KANUMA* KESIMPTA PEN OFATUMUMAB KEVZARA KISQALI SUCCINATE KISQALI FEMARA CO‐PACK RIBOCICLIB SUCCINATE/LETROZOLE KRYSTEXXA* PEGLOTICASE KUVAN SAPROPTERIN DIHYDROCHLORIDE LAPATINIB DITOSYLATE LARTRUVO* LEDIPASVIR‐SOFOSBUVIR LEDIPASVIR/SOFOSBUVIR LEMTRADA* LENVIMA MESYLATE LETAIRIS AMBRISENTAN LONSURF TRIFLURIDINE/TIPIRACIL HCL LORBRENA

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME LUCENTIS* LUMAKRAS LUMIZYME* LUPANETA PACK* LEUPROLIDE/NORETHINDRONE ACET LUXTURNA* VORETIGENE NEPARVOVEC‐RZYL LYNPARZA MACRILEN ACETATE MACUGEN* SODIUM MAVENCLAD MAVYRET GLECAPREVIR/PIBRENTASVIR MAYZENT MEKINIST DIMETHYL SULFOXIDE MEKTOVI MENOPUR MENOTROPINS MEPSEVII* VESTRONIDASE ALFA‐VJBK MIGLUSTAT HCL* MITOXANTRONE HCL MODERIBA RIBAVIRIN MONONINE* FACTOR IX MONOVISC* "HYALURONATE SODIUM, STABILIZED" MOZOBIL* PLERIXAFOR MULPLETA MVASI* BEVACIZUMAB‐AWWB MYALEPT MYLOTARG* MYOBLOC* RIMABOTULINUMTOXINB NAGLAZYME* GALSULFASE NATPARA PARATHYROID NERLYNX MALEATE NEXAVAR TOSYLATE NINLARO CITRATE NITISINONE NITYR NITISINONE NORDITROPIN FLEXPRO SOMATROPIN NORTHERA DROXIDOPA NOURIANZ ISTRADEFYLLINE NOVAREL "CHORIONIC GONADOTROPIN, HUMAN" NOVOEIGHT* "ANTIHEMOPH.FVIII,B‐DOM TRUNCAT" NOVOSEVEN RT* " FACTOR VIIA,RECOMB" NPLATE* NUBEQA DAROLUTAMIDE NUCALA NUPLAZID PIMAVANSERIN TARTRATE NUTROPIN AQ NUSPIN SOMATROPIN NUWIQ* "ANTIHEMOPH.FVIII,HEK B‐DELETE" OCALIVA OBETICHOLIC ACID OCREVUS* OCTAGAM* IMMUN GLOBG(IGG)/MALT/IGA OV50 ODOMZO PHOSPHATE OFEV ESYLATE OGIVRI* TRASTUZUMAB‐DKST OLUMIANT OMNITROPE SOMATROPIN ONUREG AZACITIDINE OPDIVO* OPSUMIT ORENCIA ORENCIA* ABATACEPT/MALTOSE ORENCIA CLICKJECT ABATACEPT ORENITRAM ER TREPROSTINIL DIOLAMINE

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME ORKAMBI LUMACAFTOR/IVACAFTOR OTEZLA OVIDREL CHORIOGONADOTROPIN ALFA OXBRYTA VOXELOTOR OXERVATE ‐BKBJ OZURDEX* PADCEV* ‐EJFV PALYNZIQ ‐PQPZ PEGASYS PEGINTERFERON ALFA‐2A PEGASYS PROCLICK PEGINTERFERON ALFA‐2A PEGINTRON PEGINTERFERON ALFA‐2B PERJETA* PHESGO* PERTUZUMAB‐TRASTUZUMAB‐HY‐ZZXF PIQRAY PLEGRIDY PEGINTERFERON BETA‐1A PLEGRIDY PEN PEGINTERFERON BETA‐1A POLIVY* ‐PIIQ POMALYST PONVORY PORTRAZZA* PREGNYL "CHORIONIC GONADOTROPIN, HUMAN" PRIVIGEN* IMMUN GLOB G(IGG)/PRO/IGA 0‐50 PROCRIT EPOETIN ALFA PROCYSBI BITARTRATE PROFILNINE* "FACTOR IX CPLX(PCC)NO4,3FACTOR" PROLEUKIN* ALDESLEUKIN PROLIA PROMACTA OLAMINE PULMOZYME DORNASE ALFA RAVICTI REBETOL RIBAVIRIN REBIF INTERFERON BETA‐1A/ALBUMIN REBIF REBIDOSE INTERFERON BETA‐1A/ALBUMIN REBINYN* "FACTOR IX HUMAN REC,PEGYLATED" RECOMBINATE* "ANTIHEMOPHILIC FACTOR, HUM REC" REMICADE* INFLIXIMAB REMODULIN* TREPROSTINIL SODIUM RENFLEXIS* INFLIXIMAB‐ABDA RETACRIT* EPOETIN ALFA‐EPBX RETEVMO RETISERT* FLUOCINOLONE ACETONIDE REVATIO* SILDENAFIL CITRATE REVATIO SILDENAFIL CITRATE REVLIMID RIABNI* ‐ARRX RIASTAP* RIBASPHERE RIBAVIRIN RIBASPHERE RIBAPAK RIBAVIRIN RIBAVIRIN RIBAVIRIN RINVOQ RITUXAN* RITUXIMAB RITUXAN HYCELA* "RITUXIMAB/HYALURONIDASE,HUMAN" RIXUBIS* FACTOR IX HUMAN RECOMBINANT ROZLYTREK RUBRACA CAMSYLATE RUCONEST* "C1 ESTERASE INHIBITOR, RECOMB" RUXIENCE* RITUXIMAB‐PVVR RYBREVANT* ‐VMJW RYDAPT SABRIL VIGABATRIN

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME SOMATROPIN SAIZEN‐SAIZENPREP SOMATROPIN SAMSCA TOLVAPTAN SANDOSTATIN LAR DEPOT* " ACETATE,MI‐SPHERES" SAPROPTERIN DIHYDROCHLOR SAPROPTERIN DIHYDROCHLORIDE SEROSTIM SOMATROPIN SEVENFACT* "COAGULATION VIIA,RECOMB‐JNCW" SILIQ SIMPONI SIMPONI ARIA* GOLIMUMAB SKYRIZI ‐RZAA SKYRIZI (2 SYRINGES) KIT RISANKIZUMAB‐RZAA SKYRIZI PEN RISANKIZUMAB‐RZAA SOFOSBUVIR‐VELPATASVIR SOFOSBUVIR/VELPATASVIR SOLIRIS* SOMATULINE DEPOT* ACETATE SOMAVERT SOVALDI SOFOSBUVIR SPINRAZA* NUSINERSEN SODIUM/PF SPRYCEL STELARA* STIMATE DESMOPRESSIN ACETATE STIVARGA SUPPRELIN LA* HISTRELIN ACETATE SUTENT MALATE SYLVANT* SYMDEKO TEZACAFTOR/IVACAFTOR SYNAGIS* PALIVIZUMAB SYNVISC* HYLAN G‐F 20 SYNVISC‐ONE* HYLAN G‐F 20 TABRECTA HYDROCHLORIDE TAFINLAR MESYLATE TAGRISSO MESYLATE TAKHZYRO ‐FLYO TALTZ AUTOINJECTOR TALTZ AUTOINJECTOR (2 PACK)IXEKIZUMAB TALTZ AUTOINJECTOR (3 PACK)IXEKIZUMAB TALTZ SYRINGE IXEKIZUMAB TALTZ SYRINGE (2 PACK) IXEKIZUMAB TALTZ SYRINGE (3 PACK) IXEKIZUMAB TALZENNA TOSYLATE TARCEVA ERLOTINIB HCL TASIGNA HCL TECENTRIQ* TECFIDERA DIMETHYL FUMARATE TEGSEDI INOTERSEN SODIUM TEMODAR TEMODAR* TEMOZOLOMIDE TEMOZOLOMIDE TEMOZOLOMIDE * TEMSIROLIMUS TEPEZZA* ‐TRBW TERIPARATIDE TERIPARATIDE TETRABENAZINE TETRABENAZINE THALOMID TIOPRONIN TIOPRONIN TOLVAPTAN TOLVAPTAN TORISEL* TEMSIROLIMUS TRACLEER BOSENTAN TRAZIMERA* TRASTUZUMAB‐QYYP TREANDA* BENDAMUSTINE HCL

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME TREMFYA TREPROSTINIL* TREPROSTINIL SODIUM TRETTEN* "FACTOR XIII A‐SUBUNIT,RECOMB" TRIKAFTA ELEXACAFTOR/TEZACAFTOR/IVACAFT TRUXIMA* RITUXIMAB‐ABBS TYKERB LAPATINIB DITOSYLATE TYMLOS TYSABRI* TYVASO TREPROSTINIL TYVASO INSTITUTIONAL START TREPROSTINIL/NEBULIZER/ACCESOR TYVASO REFILL KIT TREPROSTINIL/NEB ACCESSORIES TYVASO STARTER KIT TREPROSTINIL/NEBULIZER/ACCESOR ULTOMIRIS* ‐CWVZ UPTRAVI SELEXIPAG VALCHLOR MECHLORETHAMINE HCL VANTAS* HISTRELIN ACETATE VECTIBIX* VELCADE* VELETRI* EPOPROSTENOL SODIUM VENTAVIS ILOPROST TROMETHAMINE VERZENIO VIDAZA* AZACITIDINE VIGABATRIN VIGABATRIN VIMIZIM* ELOSULFASE ALFA VISUDYNE* VITRAKVI SULFATE VIZIMPRO VONVENDI* VON WILLEBRAND FACTOR VOSEVI SOFOSBUVIR/VELPATAS/VOXILAPREV VOTRIENT HCL VPRIV* VUMERITY DIROXIMEL FUMARATE VYNDAMAX TAFAMIDIS VYNDAQEL TAFAMIDIS MEGLUMINE WAKIX PITOLISANT HCL WILATE* ANTIHEMOPHILIC FACTOR/VWF XALKORI XELJANZ CITRATE XELJANZ XR TOFACITINIB CITRATE XELODA CAPECITABINE XEMBIFY* "IMMUNE GLOBULIN,GAMMA(IGG)KLHW" XENAZINE TETRABENAZINE XEOMIN* INCOBOTULINUMTOXINA XGEVA* DENOSUMAB XOLAIR* XTANDI ENZALUTAMIDE XYNTHA* "ANTIHEMOPH.FVIII,B‐DOMAIN DEL" XYNTHA SOLOFUSE* "ANTIHEMOPH.FVIII,B‐DOMAIN DEL" YERVOY* YONSA "ABIRATERONE ACET,SUBMICRONIZED" ZALTRAP* ZIV‐AFLIBERCEPT ZAVESCA MIGLUSTAT ZELBORAF ZEMAIRA* ALPHA‐1‐PROTEINASE INHIBITOR ZEPATIER ELBASVIR/GRAZOPREVIR ZEPOSIA HYDROCHLORIDE ZINBRYTA ZIRABEV* BEVACIZUMAB‐BVZR ZOLADEX* GOSERELIN ACETATE ZOLGENSMA* ONASEMNOGENE ABEPARVOVEC‐XIOI

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Mandatory Specialty Drug List

BRAND NAME GENERIC DRUG NME ZOLINZA ZOMACTON SOMATROPIN ZORBTIVE SOMATROPIN ZYDELIG ZYKADIA ZYTIGA ABIRATERONE ACETATE

*Drugs with an asterisk are normally administered in a clinic, infusion center or provided by home infusion services, and therefore are generally covered under the medical benefit, not the pharmacy benefit. They may also require prior authorization.

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association 017542 (07.14.2021) Discrimination is Against the Law Premera Blue Cross (Premera) complies with applicable Federal and Washington state civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. 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You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. You can also file a civil rights complaint with the Washington State Office of the Insurance Commissioner, electronically through the Office of the Insurance Commissioner Complaint Portal available at https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status, or by phone at 800-562-6900, 360-586-0241 (TDD). Complaint forms are available at https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx. Language Assistance ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-722-1471（TTY：711）。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-722-1471 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-722-1471 (TTY: 711) 번으로 전화해 주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-722-1471 (телетайп: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 800-722-1471 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 800-722-1471 (телетайп: 711). 䮚បយ័ត ៖ េបើសិន អ កនិ យ ែខ រ, េស ជំនួយែផ ក េ យមិនគិតឈ ល គឺ ច នសំ ប់បំេរអ ក។ ចូរ ទូរស័ព 800-722-1471 (TTY: 711)។ 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 800-722-1471（TTY:711）まで、お電話にてご連絡ください。 ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 800-722-1471 (መስማት ለተሳናቸው: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-722-1471 (TTY: 711). ﻣﻠﺤﻮظﺔ: إ ذ ا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن. اﺗﺼﻞ ﺑ ﺮ ﻗ ﻢ 1471-722-800 ( ر ﻗ ﻢ ھﺎﺗﻒ ا ﻟ ﺼ ﻢ واﻟﺒﻜ ﻢ: 711 .) .) ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 800-722-1471 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-722-1471 (TTY: 711). ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເ ວົ ້ າ ພາສາ ລາວ, ການບໍ ລິ ການຊ່ ວຍເ ຫື ຼ ອ ດ້ າ ນ ພາສາ, ໂ ດ ຍ ບໍ ່ ເ ສັ ຽ ຄ່ າ , ແ ມ ່ ນ ມີ ພ້ ອ ມ ໃ ຫ້ ທ່ ານ. ໂທຣ 800-722-1471 (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY: 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-722-1471 (TTY: 711). ﺗﻮﺟﮫ: ا ﮔ ﺮ ﺑ ﮫ ز ﺑ ﺎ ن ﻓﺎرﺳﯽ ﮔ ﻔ ﺘ ﮕ ﻮ ﻣ ﯽ ﮐﻨﯿﺪ، ﺗﺴﮭﯿ ﻼ ت زﺑﺎﻧ ﯽ ﺑ ﺼ ﻮ ر ت ر ا ﯾ ﮕ ﺎ ن ﺑ ﺮ ا ی ﺷ ﻤ ﺎ ﻓ ﺮ ا ھ ﻢ ﻣ ﯽ ﺑﺎﺷﺪ. ﺑ ﺎ (TTY: 711) 1471-722-800 ﺗ ﻤ ﺎ س ﺑﮕ ﯿ ﯾﺮ ﺪ . .

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