MEDICAL POLICY – 5.01.586

Intravenous Anesthetics for the Treatment of Chronic Pain

and Psychiatric Disorders BCBSA Ref. Policy: 5.01.16

Effective Date: Feb. 1, 2020

Last Revised: Jan. 9, 2020

Replaces: 5.01.16

RELATED MEDICAL POLICIES:

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POLICY CRITERIA | CODING | RELATED INFORMATION

EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Anesthetics are drugs to control pain. Anesthesia can be used to aid relaxation, block pain, or

make a person unconscious during surgery. A local anesthetic is used to block pain in a small

part of the body. Regional anesthesia is used to block pain in larger areas of the body, like the

arms or legs. General anesthesia affects the whole body and makes a person unconscious.

Different types of anesthesia have been well studied and are approved by the Food and Drug

Administration for specific uses. Other uses of anesthesia have not been as well studied. One

area of current inquiry is the use of certain anesthesias given intravenously (through a vein) to

try to treat pain from conditions like complex regional pain syndrome, fibromyalgia, or chronic

headache. Another area of inquiry is the use of anesthesias for depression, anxiety, or other

psychiatric symptoms or disorders. Using intravenous anesthetic for chronic pain or for

psychiatric disorders is investigational (unproven). More and larger studies are needed in both

of these areas.

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.

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Policy Coverage Criteria

Service Investigational Intravenous infusion of

anesthetics

Intravenous infusion of anesthetics (eg, ketamine or lidocaine)

for the treatment of chronic pain, including but not limited to

chronic neuropathic pain, chronic daily headache, and

fibromyalgia, is considered investigational.

Intravenous infusion of ketamine for the treatment of

depression, anxiety, or other psychiatric symptoms or

disorders, is considered investigational.

Coding

Code Description

CPT 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug);

initial, up to 1 hour

96366 Each additional hour (list separately in addition to code for primary procedure)

96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug);

intravenous push, single or initial substance/drug

HCPCS

J2001 Injection, lidocaine hydrochloride for intravenous infusion, 10 mg

J3490 Unclassified drugs

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

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Evidence Review

Description

Intravenous (IV) infusion of lidocaine or ketamine has been investigated for the treatment of

migraine and chronic daily headache, fibromyalgia, and chronic neuropathic pain. Chronic

neuropathic pain disorders include phantom limb pain, post-herpetic neuralgia, complex

regional pain syndrome, diabetic neuropathy, and pain related to stroke or spinal cord injuries.

An IV infusion of ketamine has also been investigated for the treatment of depression, anxiety,

post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder. For these

applications, one or more courses of IV infusion would be administered over several hours or

several days.

Background

Intravenous Anesthetic Agents

Courses of intravenous (IV) anesthetic agents may be given in the inpatient or outpatient setting

as part of a pain management program, with the infusion of a subanesthetic dose preceded by a

bolus infusion to achieve desired blood levels sooner. Treatment protocols for the initial cycle

may include infusion of subanesthetic doses of one to six hours for up to ten days.

Lidocaine

Lidocaine, which prevents neural depolarization through effects on voltage-dependent sodium

channels, is also used systemically for the treatment of arrhythmias. Adverse effects for lidocaine

are common, can be mild to moderate, and include general fatigue, somnolence, dizziness,

headache, periorbital and extremity numbness and tingling, nausea, vomiting, tremors, and

changes in blood pressure and pulse. Severe adverse events may include arrhythmias, seizures,

loss of consciousness, confusion, or even death. Lidocaine should only be given intravenously to

patients with normal conduction on electrocardiography and normal serum electrolyte

concentrations to minimize the risk of cardiac arrhythmias.

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Ketamine

Ketamine is an antagonist of the N-methyl-D-aspartate receptor and a dissociative anesthetic. It

is the sole anesthetic agent approved for diagnostic and surgical procedures that do not require

skeletal muscle relaxation. Respiratory depression may occur with overdosage or too rapid a rate

of administration of ketamine; it should be used by or under the direction of physicians

experienced in administering general anesthetics. Ketamine is a schedule III controlled

substance. Psychological manifestations vary in severity from pleasant dream-like states to

hallucinations and delirium; further, these manifestations can be accompanied by confusion,

excitement, aggression, or irrational behavior. The occurrence of adverse events with IV

anesthetics may be reduced by the careful titration of subanesthetic doses. However, the

potential benefits of pain control must be carefully weighed against the potential for serious,

harmful adverse events.

Indications

IV administration of anesthetic has been reported for various conditions, including chronic

headache, chronic pain of neuropathic origin, fibromyalgia, depression, and obsessive-

compulsive disorders.

Chronic daily headache is defined as a headache disorder that occurs more than 15 days a

month for at least 3 months. Chronic daily headache includes chronic migraine, new daily

persistent headache, hemicranias continua, and chronic tension-type headache.

Neuropathic pain is often disproportionate to the extent of the primary triggering injury and

may consist of thermal or mechanical allodynia, dysesthesia, and/or hyperalgesia. Allodynia is

pain that occurs from a stimulus that normally does not elicit a painful response (eg, light touch,

warmth). Dysesthesia is a constant or ongoing unpleasant or electrical sensation of pain.

Hyperalgesia is an exaggerated response to normally painful stimuli. In the latter, symptoms

may continue longer (eg, ≥6 months) than clinically expected after an illness or injury. It is

proposed that chronic neuropathic pain results from peripheral afferent sensitization,

neurogenic inflammation, and sympathetic afferent coupling, along with sensitization and

functional reorganization of the somatosensory, motor, and autonomic circuits in the central

nervous system. Therefore, treatments focus on reducing activity and desensitizing pain

pathways, thought to be mediated through N-methyl-D-aspartate receptors in the peripheral

and central nervous system. Sympathetic ganglion blocks with lidocaine have been used to treat

sympathetically maintained chronic pain conditions, such as complex regional pain syndrome

(previously known as reflex sympathetic dystrophy). Test infusion of an anesthetic has also been

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used in treatment planning to assess patient responsiveness to determine whether medications,

such as oral mexiletine or oral ketamine, may be effective. A course of IV lidocaine or ketamine,

usually at subanesthetic doses, has also been examined. This approach for treating chronic

neuropathic pain differs from continuous subcutaneous or IV infusion of anesthetics for

managing chronic pain conditions, such as terminal cancer pain, which is not discussed herein.

Fibromyalgia is a chronic state of widespread pain and tenderness. Although fibromyalgia is

generally considered to be a disorder of central pain processing or central sensitization, others

have proposed that the nerve stimuli causing pain originates mainly in the muscle, causing both

widespread pain and pain on movement. There are focal areas of hyperalgesia, or tender points,

which tend to occur at muscle tendon junctions. Biochemical changes associated with

fibromyalgia include alterations in N-methyl-D-aspartate receptors, low levels of serotonin,

suppression of dopamine-releasing neurons in the limbic system, dysfunction of the

hypothalamic-pituitary-adrenal axis, and elevated substance P levels. Fibromyalgia is typically

treated with neuropathic pain medications such as pregabalin, non-narcotic pain relievers, or

low doses of antidepressants.

The use of IV ketamine has also been reported for treatment-resistant depression, defined as

depression that does not respond adequately to appropriate courses of antidepressant

medications. Particularly challenging are patients with treatment-resistant depression with

suicidal ideation. Several studies are ongoing to test the efficacy of IV ketamine in patients with

suicidal ideation who present to the emergency department.

Summary of Evidence

For individuals who have chronic pain syndromes (eg, neuropathic pain or fibromyalgia) who

receive a course of IV anesthetics (eg, lidocaine, ketamine), the evidence includes several

randomized controlled trials. Relevant outcomes are symptoms, change in disease status,

morbid events, functional outcomes, quality of life, medication use, and treatment-related

morbidity. Several RCTs have been performed using IV lidocaine or ketamine for postherpetic

neuralgia (PHN), complex regional pain syndrome (CRPS), and diabetic neuropathy. Trials have

failed to show a durable effect of lidocaine infusion on chronic pain. Two trials with a total of

100 patients provide limited evidence that courses of IV ketamine may provide temporary relief

(2 to 4 weeks) to some chronic pain patients. Neither of the RCTs with ketamine infusion used

an active control, raising the possibility of placebo effects. Overall, the intense treatment

protocols, the severity of adverse events, and the limited treatment durability raise questions

about the net health benefit of this procedure. Additional clinical trials are needed to evaluate

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the long-term efficacy and safety of repeat courses of IV anesthetics for chronic pain. The

evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have psychiatric disorders (eg, treatment resistant depression (TRD), anxiety,

PTSD, obsessive-compulsive disorder) who receive a course of IV ketamine, the evidence

consists of randomized controlled trials. Relevant outcomes are symptoms, change in disease

status, morbid events, functional outcomes, quality of life, medication use, and treatment-

related morbidity. Two publications of double-blind trials were identified that compared

repeated ketamine infusion with an infusion of saline for TRD. There is a possibility of

publication bias due to the lack of publication of many other small trials that failed to show any

benefit. One study with 26 patients found no significant difference in a depression scale at the

end of infusion. A larger RCT (n=68) found a significantly greater improvement in a depression

scale during the 4-week infusion period, but the effect diminished over 3 weeks post-infusion.

The trial did not use an active control in addition to a placebo arm, raising the possibility of

placebo effects. Common side effects of ketamine infusion include headache, anxiety,

dissociation, nausea, and dizziness. The intense treatment protocols, the severity of adverse

events, and the limited treatment durability raise questions about the net health benefit of this

procedure. High-quality clinical trials, several of which are in progress, are needed to evaluate

the long-term safety and efficacy of IV ketamine for psychiatric disorders.

Although reports of reduction in depression, anxiety, and suicidal ideation are promising, the

strength of evidence is weak, limited by relatively small sample sizes, loss of effectiveness after 2

to 7 days, lack of longer-term data on efficacy, limited data on safety, and lack of blinding even

in double-blind randomized controlled trials. As one expert has noted, it is relatively easy for

subjects and investigators to distinguish between the effects of ketamine and saline, which is

used most often as the control agent, or midazolam, which was used as the control agent in a

recently published study. The midazolam-controlled trial purported to demonstrate a significant

reduction in suicidal ideation within 24 hours, but was also limited by open-label uncontrolled

assessment after day 1 for up to 6 weeks, and by the fact that the study population was a cohort

of psychiatric inpatients; there is no evidence that their experience can be generalized to

patients in outpatient or other settings. The evidence is therefore insufficient to determine the

effects of the technology on health outcomes.

Ongoing and Unpublished Clinical Trials

Around 100 completed or ongoing trials evaluating intravenous infusion of ketamine for

depression are listed on clinicaltrials.gov. Most of these studies are phase 1 with fewer than 20

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patients and many are completed but not published. Some currently ongoing and unpublished

trials that include over 40 are listed in Table 1.

Table 1. Summary of Key Trials

NCT No. Trial Name Planned

Enrollment

Completion

Date

Ongoing

NCT02556606 Ketamine for Treatment-Resistant Late-Life Depression 72 Sep 2020

NCT02461927 Ketamine for The Rapid Treatment of Major Depression

and Alcohol Use Disorder

65 Jun 2021

NCT03666390 A Double-blind, Randomized-controlled Trial Using a Low

Dose of Ketamine vs Active Placebo in Treating Severe

Depression and Suicide

48 Dec 2021

NCT03674671 Investigations on the Efficacy of Ketamine in Depression in

Comparison to Electroconvulsive Therapy

240 Dec 2021

NCT03113968 ELEKT-D: Electroconvulsive Therapy (ECT) vs Ketamine in

Patients With Treatment-Resistant Depression (TRD)

400 Apr 2022

NCT03237286 Testing a Synergistic, Neuroplasticity-Based Intervention

for Depressive Neurocognition

150 Oct 2023

Unpublished

NCT01920555 Double-Blind, Placebo-Controlled Trial of Ketamine

Therapy in Treatment-Resistant Depression (TRD)

99 Feb 2017

(completed)

NCT02299440 Evaluation of the Effects of Ketamine in the Acute Phase of

Suicidal Ideation: a Multicenter Randomized Double-blind

Trial

156 Mar 2019

(completed)

NCT02659085 A Randomized Controlled Non-inferiority Trial Comparing

Ketamine With ECT in Patients With Major Depressive

Disorder

200 Dec 2018

NCT02360280 Intravenous Sub-anesthetic Ketamine Treatment in

Treatment-Resistant Depression

62 Mar 2019

(completed)

NCT: national clinical trial

https://clinicaltrials.gov/ct2/show/NCT02556606?term=NCT02556606&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT02461927?term=NCT02461927&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT03666390?term=NCT03666390&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT03674671?term=NCT03674671&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT03113968?term=NCT03113968&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT03237286?term=NCT03237286&draw=1&rank=1https://www.clinicaltrials.gov/ct2/show/NCT01920555?term=NCT01920555&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02299440?term=NCT02299440&rank=1https://clinicaltrials.gov/ct2/show/NCT02659085?term=NCT02659085&draw=1&rank=1https://clinicaltrials.gov/ct2/show/NCT02360280?term=NCT02360280&draw=1&rank=1

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Practice Guidelines and Position Statements

The practice guidelines on managing chronic pain from the American Society of

Anesthesiologists and the American Society of Regional Anesthesia and Pain Medicine (2010)

discussed various treatments for chronic pain.15 Use of ionotropic N-methyl-D-aspartate

receptor antagonists and topical agents for neuropathic pain was addressed; IV infusion of

lidocaine or ketamine was not.

The American Psychiatric Association (2017) published an evidence review and consensus

opinion of the use of ketamine in treatment-resistant depression.16 The Association noted that

"while ketamine may be beneficial to some patients with mood disorders, it is important to

consider the limitations of the available data and the potential risk associated with the drug

when considering the treatment option."

Medicare National Coverage

There is no national coverage determination.

Regulatory Status

IV lidocaine is approved by the U.S. Food and Drug Administration (FDA) for systemic use in the

acute treatment of arrhythmias and locally as an anesthetic; IV lidocaine for the treatment of

chronic pain or psychiatric disorders is an off-label use.

Ketamine hydrochloride injection is approved for diagnostic and surgical procedures that do not

require skeletal muscle relaxation, for the induction of anesthesia before the administration of

other general anesthetic agents, and to supplement low-potency agents, such as nitrous oxide.

IV ketamine for the treatment of chronic pain or psychiatric disorders is an off-label use.

References

1. Wertli MM, Kessels AG, Perez RS, et al. Rational pain management in complex regional pain syndrome 1 (CRPS 1)--a network

meta-analysis. Pain Med. Sep 2014;15(9):1575-1589. PMID 25234478.

2. Schwartzman RJ, Alexander GM, Grothusen JR, et al. Outpatient intravenous ketamine for the treatment of complex regional

pain syndrome: a double-blind placebo controlled study. Pain. Dec 15 2009;147(1-3):107-115. PMID 19783371.

Page | 9 of 10 ∞

3. Sigtermans MJ, van Hilten JJ, Bauer MC, et al. Ketamine produces effective and long-term pain relief in patients with Complex

Regional Pain Syndrome Type 1. Pain. Oct 2009;145(3):304-311. PMID 19604642.

4. O'Connell NE, Wand BM, McAuley J, et al. Interventions for treating pain and disability in adults with complex regional pain

syndrome. Cochrane Database Syst Rev. 2013;4:CD009416. PMID 23633371.

5. Kim YC, Castaneda AM, Lee CS, et al. Efficacy and safety of lidocaine infusion treatment for neuropathic pain: a randomized,

double-blind, and placebo-controlled study. Reg Anesth Pain Med. May 2018;43(4):415-424. PMID 29381569.

6. Liu H, Lu F, Zhou D et al. The Analgesic and Emotional Response to Intravenous Lidocaine Infusion in the Treatment of

Postherpetic Neuralgia: A Randomized, Double-Blinded, Placebo-controlled Study. Clin J Pain, 2018 Apr 27;34(11). PMID

29698250.

7. Moulin DE, Morley-Forster PK, Pirani Z et al. Intravenous lidocaine in the management of chronic peripheral neuropathic pain: a

randomized-controlled trial. Can J Anaesth, 2019 May 18;66(7). PMID 31098961.

8. Amr YM. Multi-day low dose ketamine infusion as adjuvant to oral gabapentin in spinal cord injury related chronic pain: a

prospective, randomized, double blind trial. Pain Physician. May-Jun 2010;13(3):245-249. PMID 20495588.

9. Patil S, Anitescu M. Efficacy of outpatient ketamine infusions in refractory chronic pain syndromes: a 5-year retrospective

analysis. Pain Med. Feb 2012;13(2):263-269. PMID 21939497.

10. Przeklasa-Muszynska A, Kocot-Kepska M, Dobrogowski J, et al. Intravenous lidocaine infusions in a multidirectional model of

treatment of neuropathic pain patients. Pharmacol Rep. Oct 2016;68(5):1069-1075. PMID 27552062

11. Noppers I, Niesters M, Swartjes M, et al. Absence of long-term analgesic effect from a short-term S-ketamine infusion on

fibromyalgia pain: a randomized, prospective, double blind, active placebo-controlled trial. Eur J Pain. Oct 2011;15(9):942-949.

PMID 21482474

12. Vlainich R, Issy AM, Sakata RK. Effect of intravenous lidocaine associated with amitriptyline on pain relief and plasma serotonin,

norepinephrine, and dopamine concentrations in fibromyalgia. Clin J Pain. May 2011;27(4):285-288. PMID 21178598.

13. Singh JB, Fedgchin M, Daly EJ et al. A Double-Blind, Randomized, Placebo-Controlled, Dose-Frequency Study of Intravenous

Ketamine in Patients With Treatment-Resistant Depression. Am J Psychiatry, 2016 Apr 9;173(8). PMID 27056608.

14. Ionescu DF, Bentley KH, Eikermann M et al. Repeat-dose ketamine augmentation for treatment-resistant depression with

chronic suicidal ideation: A randomized, double blind, placebo controlled trial. J Affect Disord, 2018 Oct 5;243:516-524. PMID

30286416.

15. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and

Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of

Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain

Medicine. Anesthesiology. Apr 2010;112(4):810-833. PMID 20124882

16. Sanacora G, Frye MA, McDonald W, et al. A consensus statement on the use of ketamine in the treatment of mood disorders.

JAMA Psychiatry. Apr 2017;74(4):399-405. PMID 28249076

17. Nemeroff C. Ketamine: quo vadis? American Journal of Psychiatry. Apr 2018;175(4):297-299. PMID 29606064

18. Grunebaum M, Galfalvy H, Choo T, et al. Ketamine for rapid reduction of suicidal thoughts in major depression: a midazolam-

controlled randomized clinical trial. American Journal of Psychiatry. Apr 2018;175(4):327-335. PMID 29202655

History

Page | 10 of 10 ∞

Date Comments 08/01/18 New policy, approved July 10, 2018. This policy replaces 5.01.16; Policy title and Policy

Coverage Criteria amended to include IV ketamine for psychiatric symptoms and

disorders. References 35-37 added.

02/01/19 Annual Review, approved January 4, 2019. Policy updated with literature review

through September 2018; reference 8 added. Policy statement unchanged.

02/01/20 Annual Review, approved January 9, 2020. Policy updated with literature review

through October 2019; references added. Policy statements unchanged.

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Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357).

Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum 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 Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357).

Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).

Italiano ( ):Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).

Italian

中文 (Chinese):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

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

語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。

037338 (07-2016)

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@Premera.com

日本語 (Japanese):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 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

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

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

トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນີ້. ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົດ ເວລາສະເພາະເພື່ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລື່ອງ າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນີ້ ແລະ ຄວາມຊ່ວຍເຫຼື ອເປັ ນພາສາ ຂອງທ່ານໂດຍບ່ໍ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357).

ູຂໍ້

່

ສໍ ັ

ຈ

ໝ

ສິ

ັ

່

ວ

ຄ

ມ

ມູຮັ

ູມີ ມຂໍ້

ភាសាែខមរ ( ): ឹ

រងរបស់

Premera Blue Cross ។ របែហលជាមាន កាលបរ ិ ឆ ំខានេនៅកងេសចក

េសចកតជី ូ

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់

នដំ ងេនះមានព័ ី

តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ណ ត៌មានយ៉ា ំ ់ តងសខាន។ េសចក

េចទស ់ ន ុ ត

ណងេនះ។ អ វការបេញញសមតភាព ដលកណតៃថ ចបាស

កតាមរយៈ

ដំ ឹ នករបែហលជារតូ ច ថ ់ ំ ់ ងជាក់ ់

នដ

ន

ី ន

ូ

អ

ូ

ជ

ជ

ំណឹងេនះរបែហល

នានា េដើ ីនងរកសាទុ ៉ បរងស់ ុ ់ ក ឬរបាក់ ំ

អ

មប ឹ កការធានារា ខភាពរបស ជ

ធនកមានសិ ទទលព័ មានេនះ និ ំ យេនៅកុងភាសារបសទិ ួ ត៌ ងជ ននួ

ន

់ កេដាយម

អ

នអ

យេចញៃថល។ ួ

នអស

ន

ិ

លុ ើ ូ ូយេឡយ។ សមទ ទ រស័ព 800-722-1471 (TTY: 800-842-5357)។

Khmer

ਕਵਰਜ ਅਤ ਅਰਜੀ ਬਾਰ ਮਹ ਤਵਪਰਨ ਜਾਣਕਾਰੀ ਹ ਸਕਦੀ ਹ . ਇਸ ਨ ਿਜਸ ਜਵਚ ਖਾਸ

ਤਾਰੀਖਾ ਹ ਸਕਦੀਆ ਹਨ. ਜੇਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚ ਮਦਦ ਦ ੇਇਛ ੁਕ ਹ ਤਾਂ ਤਹਾਨ ਅ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ ਝ ਖਾਸ ਕਦਮ ਚ ਕਣ ਦੀ ਲੜ ਹ ਸਕਦੀ ਹ ,ਤਹੁਾਨ ਮਫ਼ਤ ਿਵਚ ਤ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਚ ਜਾਣਕਾਰੀ ਅਤ ਮਦਦ ਪਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).

ਪ ਜਾਬੀ (Punjabi): ਇਸ ਨ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ. ਇਸ ਨ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ

ੰ

ੰ

ੇ ੇ ੇ ੱ ੂ ੋ ੈ ੋੋ ਂ ੁ ੇ ੱ ੋ ੇ ੱੱ ੁ ੱ ੂੁ ੱ ੇ ੱ ੇ ੍ਰ ੈ

ੋ ੰ ੂ ੱ ੁ ੋ ੋ ੈ ੰ

ੋ ੈ ੋ

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين. ميباشد ھمم اطالعات یوحا يهمالعا اين

در ھمم ھای خيتار به باشد.پ رایبستاکنممماش زينهھ اختدپر در مککيا تان بيمهوشش حقظ

Premera Blue Cross طريق از ماش مهبيوشش يا و تقاضا ای پ. يدماين جهتو يهمالعا اين

حق شما. يدشاب داشته اجتياح صیاخ کارھای امانج برای صیمشخ ایھ خيتار به تان، انیمدر ھای کسب برای .نماييد دريافت گانيرا ورط به ودخ زبان به را کمک و اطالعات اين که داريد را اين

استم ) 5357-842-800 مارهباش ماست TTY انکاربر(800-722-1471 مارهش با اطالعات .اييدنم برقرار

้

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może

zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357).

Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter e sta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua 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 aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai 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 ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357).

Español ( ): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este

tiene derecho a recibir esta información y ayuda en su idioma sin costo

aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted

alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

Spanish

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).

ไทย (Thai): ประกาศนมขอมลสาคญ ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน สขภาพของคณผาน Premera Blue Cross และอาจมกาหนดการในประกาศน คณอาจจะตอง ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท มคาใชจาย คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่มคาใชจาย โทร 800-722-1471 (TTY: 800-842-5357)

้ี ี ้ ู ํ ั ้ี ี ้ ู ่ี ํ ั ่ี ั ั ื ัุ ุ ่ ี ํ ี ุ ้ํ ิ ํ ่ี ่ ่ื ั ั ุ ุ ื ่ ื ่ีี ่ ้ ่ ุ ี ิ ิ ่ี ้ ั ้ ู ่ ื ้ี ุ ี ่ ้ ่

Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn 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).