MEDICAL POLICY – 7.03.01

Kidney Transplant

BCBSA Ref. Policy: 7.03.01, 7.03.14

Effective Date: June 10, 2020

Last Revised: June 9, 2020

Replaces: Extracted from

7.03.509

RELATED MEDICAL POLICIES:

7.03.02 Allogeneic Pancreas Transplant

Select a hyperlink below to be directed to that section.

POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING

RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

An organ transplant is the surgical process of replacing a severely diseased organ with a healthy

one from a donor. The donated organ can come from a living person or a person who passed

away from an accident or illness. Organ failure is the most common reason a transplant is

needed. Organ failure can occur because of illness, injury, or birth defect. There are many factors

that go into finding a donor organ that matches. These include blood type and the size of the

organ. Other factors include how long a person has been on the waiting list, the level of illness,

and the distance the donated organ must be transported. This policy describes when

transplanting a kidney may be considered medically necessary. This policy notes that a plan

physician will review solid organ transplant requests together with the criteria of the transplant

center.

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

https://www.premera.com/medicalpolicies-individual/7.03.02.pdf

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Transplant Medical Necessity Kidney transplant Kidney transplants with either a living or deceased (cadaver)

donor may be considered medically necessary for patients with

documented end-stage renal disease.

Kidney retransplant after a failed primary kidney transplant

may be considered medically necessary in patients who meet

criteria for kidney transplantation.

Note: See Related Information

Transplant Investigational All other situations Kidney transplant is considered investigational in all other

situations not described above.

HCV-viremic (hepatitis C)

organs

The transplantation of HCV-viremic solid organs (kidney, lung,

heart, liver, small bowel, pancreas) to an HCV non-viremic

recipient combined with direct-acting antiviral treatment for

HCV is considered investigational.

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 relevant history and physical documenting the patient has

end-stage renal disease.

Coding

Code Description

CPT 50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy

50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy

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Code Description

HCPCS

S2065 Simultaneous pancreas kidney transplantation

S2152 Solid organ(s), complete or segmental, single organ or combination of organs;

deceased or living donor (s), procurement, transplantation, and related complications;

including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical,

diagnostic, emergency, and rehabilitative services, and the number of days of pre and

posttransplant care in the global definition

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

Renal-Specific Criteria

Indications for renal transplant include a creatinine level of greater than 8 mg/dL, or greater

than 6 mg/dL in symptomatic diabetic patients; however, consideration for listing for renal

transplant may start well before the creatinine level reaches this point, based on the anticipated

time that a patient may spend on the waiting list.

Contraindications

Potential contraindications to solid organ transplant (subject to the judgment of the transplant

center):

• Known current malignancy, including metastatic cancer

• Recent malignancy with high risk of recurrence

• History of cancer with a moderate risk of recurrence

• Systemic disease that could be exacerbated by immunosuppression

• Untreated systemic infection making immunosuppression unsafe, including chronic infection

• Other irreversible end-stage diseases not attributed to kidney disease

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• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy

Benefit Application

See member’s plan contract language for organ transplant benefits and specific benefits related

to transport, lodging, and donor services. Please note limitations in coverage based on the

transplant benefit, if applicable.

Evidence Review

Description

Kidney transplant, a treatment option for end-stage renal disease (ESRD), involves the surgical

removal of a kidney from a cadaver, living-related donor, or living-unrelated donor and

transplantation into the recipient.

Background

End-Stage Renal Disease

ESRD refers to the inability of the kidneys to perform their functions (ie, filtering wastes and

excess fluids from the blood). ESRD, which is life-threatening, is also known as stage 5 chronic

renal failure and is defined as a glomerular filtration rate less than 15 mL/min/1.73 m2.1

Treatment

Dialysis is an artificial replacement for some kidney functions. Dialysis is used as a supportive

measure in patients who do not want kidney transplants or who are not transplant candidates; it

can also be used as a temporary measure in patients awaiting a kidney transplant.

Kidney transplant, using kidneys from deceased or living donors, is an accepted treatment of

ESRD. Based on data from the Organ Procurement and Transplantation Network, in 2017, over

10,300 kidney transplants were performed in the U.S. Since 1988, the cumulative number of

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kidney transplants is over 435,500.2 Of the cumulative total, 66% of the kidneys came from

deceased donors and 34% from living donors.

Combined kidney and pancreas transplants and management of acute rejection of kidney

transplant using either intravenous immunoglobulin or plasmapheresis are discussed in separate

medical policies.

Summary of Evidence

For individuals who have end-stage renal disease without contraindications to kidney transplant

who receive a kidney transplant from a living donor or deceased (cadaveric) donor, the evidence

includes registry data and case series. The relevant outcomes are overall survival, morbid events,

and treatment-related mortality and morbidity. Data from large registries have demonstrated

reasonably high survival rates after kidney transplant for appropriately selected patients and

significantly higher survival rates for patients undergoing kidney transplant compared with those

who remained on a waiting list. Kidney transplantation is contraindicated for patients in whom

the procedure is expected to be futile due to comorbid disease or in whom posttransplantation

care is expected to significantly worsen comorbid conditions. The evidence is sufficient to

determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have a failed kidney transplant without contraindications to kidney

transplant who receive a kidney retransplant from a living donor or deceased (cadaveric) donor,

the evidence includes registry data and case series. The relevant outcomes are overall survival,

morbid events, and treatment-related mortality and morbidity. Data have demonstrated

reasonably high survival rates after kidney retransplant (eg, 5-year survival rates ranging from

87% to 96%) for appropriately selected patients. Kidney retransplantation is contraindicated for

patients for whom the procedure is expected to be futile due to comorbid disease or for whom

posttransplantation care is expected to significantly worsen comorbid conditions. The evidence

is sufficient to determine that the technology results in a meaningful improvement in the net

health outcome.

For individuals who are HCV non-viremic who have end-stage renal disease and are candidates

for a kidney transplant the evidence for the use of HCV viremic donor organs as an alternative to

continuing dialysis or other appropriate treatment and remaining on the transplant wait-list

consists of preliminary results of two open-label nonrandomized trials

(THINKER and EXPANDER). The primary outcomes were sustained virologic response (SVR) and

graft function and survival. Major adverse events attributable to the selected HCV direct-acting

antiviral agents (DAA) regimen was also assessed. To date, the experience of 30 participants has

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been reported in the literature. Participants generally had comparable demographic

characteristics. The studies differed in whether or not donor kidneys were genotyped in advance

of transplantation. Appropriate DAA regimens were chosen to match genotype or pangenotypic

was used. There were differences in the timing of administration of the DAA regimen, but all

participants were followed to ascertain the need for extension of the original regimen or

addition of another drug. All recipients showed evidence of HCV nucleic acid positivity and viral

loads were determined in some instances. All recipients had SVR by the completion of the

appropriate DAA regimen with the longest follow-up out to 12 months in 10 participants. There

were no reports of allograft rejection or renal function abnormalities. Transient elevations in liver

transaminases were reported but not in all participants. Assessment of quality of life (QOL) by

the standard patient-reported measures in the first ten participants of the THINKER cohort

indicated that QOL was initially diminished in the early postoperative period. At 12 months, the

physical component score of the RAND-36 questionnaire improved beyond baseline but the

mental component score returned to baseline. The evidence is insufficient to determine the

effects of the technology on health outcomes.

Ongoing and Unpublished Clinical Trials

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

Table 1. Summary of Key Trials

NCT No. Trial Name Planned

Enrollment

Completion

Date

Ongoing

NCT03500315 HOPE in Action Prospective Multicenter, Clinical Trial of

Deceased HIVD+ Kidney Transplants for HIV+ Recipients

360 Aug 2022

NCT02669966 Live Kidney Donors with Positive Anti-HCV Antibody, But

Negative HCV PCR

6 Jun 2020

NCT02945150 Preemptive Treatment with Grazoprevir and Elbasvir for

Donor HCV Positive to Recipient HCV Negative Kidney

Transplant

40 Sept 2020

NCT02743897 Open-Labeled Trial of Zepatier For Treatment of Hepatitis

C-Negative Patients Who Receive Kidney Transplants from

Hepatitis C-Positive Donors (THINKER)

75 Dec 2021

https://www.clinicaltrials.gov/ct2/show/NCT03500315?term=NCT03500315&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02669966?term=NCT02669966&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02945150?term=NCT02945150&rank=1https://www.clinicaltrials.gov/ct2/show/NCT02743897?term=NCT02743897&rank=1

Page | 7 of 10 ∞

NCT No. Trial Name Planned

Enrollment

Completion

Date

NCT03801707 An Open Label, Prospective, Interventional, Proof of

Concept Study to Evaluate the Feasibility and Safety of

Kidney Transplant from HCV Positive Donors into HCV

Negative Recipient Using Sofosbuvir/Velpatasvir as a

Treatment for Post-Transplant HCV Transmission

25 Jan 2022

NCT: National clinical trial

Practice Guidelines and Position Statements

American Society of Transplant Surgeons et al

The American Society of Transplant Surgeons, the American Society of Transplantation, the

Association of Organ Procurement Organizations, and the United Network for Organ Sharing

(2011) issued a joint position statement recommending modifications to the National Organ

Transplant Act of 1984.23 The joint recommendation stated that the potential pool of organs

from HIV-infected donors should be explored. With modern antiretroviral therapy, the use of

these previously banned organs would open an additional pool of donors to HIV-infected

recipients. The increased pool of donors has the potential to shorten waiting times for organs

and decrease the number of waiting list deaths. The organs from HIV-infected deceased donors

would be used for transplant only with patients already infected with HIV. In 2013, the HIV

Organ Policy Equity Act permitting the use of this group of organ donors.

The American Society of Transplantation

The American Society of Transplantation (2017) convened a consensus conference of experts to

address issues related to the transplantation of hepatitis C virus (HCV) viremic solid organs into

HCV non-viremic recipients and concluded that the transplantation of organs from HCV viremic

donors into HCV-negative recipients should be conducted only under monitored IRB-approved

protocols and studies.

https://www.clinicaltrials.gov/ct2/show/NCT03801707?term=NCT03801707&rank=1

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Medicare National Coverage

The Medicare Benefit Policy Manual includes a chapter on end-stage renal disease.24 A section

on identifying candidates for transplantation (140.1) states:

After a patient is diagnosed as having ESRD [end-stage renal disease], the physician should

determine if the patient is suitable for transplantation. If the patient is a suitable transplant

candidate, a live donor transplant is considered first because of the high success rate in

comparison to a cadaveric transplant. Whether one or multiple potential donors are

available, the following sections provide a general description of the usual course of events

in preparation for a live-donor transplant.

Regulatory Status

A kidney transplant is a surgical procedure and, as such, is not subject to regulation by the U.S.

Food and Drug Administration.

The U.S. Food and Drug Administration regulates human cells and tissues intended for

implantation, transplantation, or infusion through the Center for Biologics Evaluation and

Research, under Code of Federal Regulation Title 21, parts 1270 and 1271. Kidney transplants

are included in these regulations.

References

1. National Kidney Foundation. Glomerular Filtration Rate (GFR). n.d.; https://www.kidney.org/atoz/content/gfr Accessed

October 2019.

2. Organ Procurement and Transplantation Network. View Data Reports. n.d.; https://optn.transplant.hrsa.gov/data/view-data-

reports Accessed October 2019.

3. Krishnan N, Higgins R, Short A, et al. Kidney transplantation significantly improves patient and graft survival irrespective of BMI:

a cohort study. Am J Transplant. Sep 2015;15(9):2378-2386. PMID 26147285.

4. Querard AH, Foucher Y, Combescure C, et al. Comparison of survival outcomes between Expanded Criteria Donor and Standard

Criteria Donor kidney transplant recipients: a systematic review and meta-analysis. Transpl Int. Apr 2016;29(4):403-415. PMID

26756928.

5. Pestana JM. Clinical outcomes of 11,436 kidney transplants performed in a single center - Hospital do Rim. J Bras Nefrol. Aug 28

2017;39(3):287-295. PMID 28902233.

6. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. Jama. Mar

10 2010;303(10):959-966. PMID 20215610.

https://www.kidney.org/atoz/content/gfrhttps://optn.transplant.hrsa.gov/data/view-data-reportshttps://optn.transplant.hrsa.gov/data/view-data-reports

Page | 9 of 10 ∞

7. Muller E, Barday Z, Mendelson M, et al. HIV-positive-to-HIV-positive kidney transplantation--results at 3 to 5 years. N Engl J

Med. 2015 372(7):613-620. PMID 25671253.

8. Locke JE, Reed RD, Mehta SG, et al. Center-level experience and kidney transplant outcomes in HIV-infected recipients. Am J

Transplant. Aug 2015;15(8):2096-2104. PMID 25773499.

9. Locke JE, Mehta S, Reed RD, et al. A national study of outcomes among HIV-infected kidney transplant recipients. J Am Soc

Nephrol. Sep 2015;26(9):2222-2229. PMID 25791727.

10. Locke JE, Gustafson S, Mehta S, et al. Survival benefit of kidney transplantation in HIV-infected patients. Ann Surg. Mar

2017;265(3):604-608. PMID 27768622.

11. Sawinski D, Forde KA, Eddinger K, et al. Superior outcomes in HIV-positive kidney transplant patients compared with HCV-

infected or HIV/HCV-coinfected recipients. Kidney Int. Aug 2015;88(2):341-349. PMID 25807035.

12. Organ Procurement and Transplantation Network (OPTN). Organ Procurement and Transplantation Network Policies. 2018;

https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdf Accessed October 2019.

13. Working Party of the British Transplantation Society. Kidney and Pancreas Transplantation in Patients with HIV. Second Edition

(Revised). British Transplantation Society Guidelines. Macclesfield, UK: British Transplantation Society; 2017.

14. Fabrizi F, Martin P, Dixit V, et al. Meta-analysis of observational studies: hepatitis C and survival after renal transplant. J Viral

Hepat. May 2014;21(5):314-324. PMID 24716634.

15. Gill JS, Lan J, Dong J, et al. The survival benefit of kidney transplantation in obese patients. Am J Transplant. Aug

2013;13(8):2083-2090. PMID 23890325.

16. Pieloch D, Dombrovskiy V, Osband AJ, et al. Morbid obesity is not an independent predictor of graft failure or patient mortality

after kidney transplantation. J Ren Nutr. Jan 2014;24(1):50-57. PMID 24070588.

17. Kwan JM, Hajjiri Z, Metwally A, et al. Effect of the obesity epidemic on kidney transplantation: obesity is independent of

diabetes as a risk factor for adverse renal transplant outcomes. PLoS One. Nov 2016;11(11):e0165712. PMID 27851743.

18. Kervinen, MG, Lehto S, Helve J, et al. Type 2 diabetic patients on renal replacement therapy: Probability to receive renal

transplantation and survival after transplantation. PLoS One. 2018 Aug 15;13(8):e0201478. PMID 30110346.

19. Lim WH, Wong G, Pilmore HL, et al. Long-term outcomes of kidney transplantation in people with type 2 diabetes: a population

cohort study. Lancet Diabetes Endocrinol. Jan 2017;5(1):26-33. PMID 28010785.

20. Barocci S, Valente U, Fontana I, et al. Long-term outcome on kidney retransplantation: a review of 100 cases from a single

center. Transplant Proc. May 2009;41(4):1156-1158. PMID 19460504.

21. Gupta M, Wood A, Mitra N, et al. Repeat kidney transplantation after failed first transplant in childhood: past performance

informs future performance. Transplantation. Aug 2015;99(8):1700-1708. PMID 25803500.

22. Shelton BA, Mehta S, Sawinski D, et al. Increased mortality and graft loss with kidney retransplantation among human

immunodeficiency virus (HIV)-infected recipients. Am J Transplant. Jan 2017;17(1):173-179. PMID 27305590.

23. American Society of Transplant Surgeons (ASTS), The American Society of Transplantation (AST), The Association of Organ

Procurement Organizations (AOPO), et al. Statement on transplantation of organs from HIV-infected deceased donors. 2011;

http://asts.org/docs/default-source/position-statements/transplantation-of-organs-from-hiv-infected-deceased-

donors-july-22-2011.pdf?sfvrsn=4 Accessed October 2019.

24. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 11 - End Stage Renal Disease (ESRD). 2018;

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf Accessed October 2019.

25. Levitsky J, Formica RN, Bloom RD, et al. The American Society of Transplantation Consensus Conference on the Use of Hepatitis

C Viremic Donors in Solid Organ Transplantation. Am J Transplant. Nov 2017;17(11):2790-2802. PMID 28556422.

26. Goldberg DS, Abt PL, Blumberg EA, et al. Trial of Transplantation of HCV-Infected Kidneys into Uninfected Recipients. N Engl J

Med. Jun 15 2017;376(24):2394-2395. PMID 28459186.

https://optn.transplant.hrsa.gov/media/1200/optn_policies.pdfhttp://asts.org/docs/default-source/position-statements/transplantation-of-organs-from-hiv-infected-deceased-donors-july-22-2011.pdf?sfvrsn=4http://asts.org/docs/default-source/position-statements/transplantation-of-organs-from-hiv-infected-deceased-donors-july-22-2011.pdf?sfvrsn=4https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c11.pdf

Page | 10 of 10 ∞

27. Reese PP, Abt PL, Blumberg EA, et al. Twelve-Month Outcomes After Transplant of Hepatitis C-Infected Kidneys Into Uninfected

Recipients: A Single-Group Trial. Ann Intern Med. Sep 4 2018;169(5):273-281. PMID 30083748.

28. Durand CM, Bowring MG, Brown DM, et al. Direct-Acting Antiviral Prophylaxis in Kidney Transplantation From Hepatitis C Virus-

Infected Donors to Noninfected Recipients: An Open-Label Nonrandomized Trial. Ann Intern Med. Apr 17 2018;168(8):533-540.

PMID 29507971

History

Date Comments 11/01/19 New policy, approved October 4, 2019. Content previously addressed in policy

7.03.509. Policy created with literature review through June 2019. Kidney

transplantation may be considered medically necessary when criteria are met,

considered investigational when criteria are not met. Policy statement on

transplantation of HCV viremic organs is taken from BCBSA policy 7.03.14.

04/01/20 Delete policy, approved March 10, 2020. This policy will be deleted effective July 2,

2020, and replaced with InterQual criteria for dates of service on or after July 2, 2020.

06/10/20 Interim Review, approved June 9, 2020, effective June 10, 2020. This policy is reinstated

immediately and will no longer be deleted or replaced with InterQual criteria on July 2,

2020.

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). ©2020 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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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).