PHARMACY BENEFIT COVERAGE GUIDELINE – 5.01.542

Medical Necessity Criteria for Medication Safety:

Controlled Substances Utilization Service Program

Effective Date: Jan. 1, 2020

Last Revised: Dec. 10, 2019

Replaces: N/A

RELATED GUIDELINES / POLICIES:

5.01.529 Management of Opioid Therapy

Select a hyperlink below to be directed to that section.

COVERAGE GUIDELINES | CODING | RELATED INFORMATION | REFERENCES | HISTORY

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Introduction

A controlled medication is a drug that is legal to use with a prescription but is highly regulated

because of the potential for physical and mental dependence. Controlled medications are

grouped into five classes by the Drug Enforcement Administration. The classes are based on a

particular drug’s medical use, safety, and potential for abuse and/or dependence. While the vast

majority of people who get prescriptions for controlled medications use them responsibly, there

are some cases where prescription patterns point to overuse, misuse, or giving or selling the

medication to others. In such cases, this policy describes the steps to ensure how a person can

get their needed medication in safe quantities through a single provider.

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.

Coverage Guidelines

https://www.lifewisewa.com/medicalpolicies/5.01.529.pdf

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Restriction Medical Necessity One-provider restriction One-Provider restriction may be considered medically

necessary when there is evidence of excessive use, misuse,

non-medical use, or diversion of one or more controlled

substances by a member, and when one or more attempts to

contact and work with the member to establish a plan for

appropriate management of controlled substances via case

management, chemical dependency treatment, enrollment in a

pain management program, or self-imposed restriction to one

prescriber, have failed.

When restricted to one-provider, a single provider will be

identified for coverage of prescriptions of all controlled

substances for the member. The pharmacy claims system will

be locked to prevent coverage of prescriptions of controlled

medications unless they are prescribed by that provider.

The existence of any one or more of the following criteria or

behaviors may be used to identify individuals who may be

engaged in the excessive use, misuse, non-medical use, or

diversion of controlled substances:

• Pattern of simultaneous or overlapping controlled substance

prescribing involving multiple prescribers and/or pharmacies.

This includes but is not limited to:

o Multiple prescribers of same or similar controlled

substances within overlapping timeframes;

o Fills of controlled substances at multiple pharmacies within

overlapping timeframes

• Long-term, unusually high and escalating doses of controlled

substances. This includes but is not limited to:

o Total daily opioid dose of more than 120mg Morphine

Equivalent Dose (MED), also known as Morphine Milligram

Equivalent (MME)

• Frequent early refill requests

• Altered (any occurrence) or forged prescriptions

• Multiple reports of misplaced, lost, or stolen medications or

prescriptions

• Increasing symptoms in spite of being on controlled substances

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Restriction Medical Necessity • Declining activity or functioning in spite of being prescribed

controlled substances

• Missing medical appointments except when a refill is expected

or needed

• Unwilling to try other non-controlled pharmacologic and non-

pharmacologic treatments

• Insistence on a specific controlled substance

• Reports of, or appearing to be:

o Intoxicated, somnolent, or sedated; or

o Exhibiting withdrawal symptoms

• Abnormal results on drug screening tests, such as opioids or

cannabinoids when none should be present, or absence of

opioid when they are being prescribed and should be present

on testing

• Unwillingness or inability to take medications as prescribed

• Concurrent prescriptions for buprenorphine (Suboxone or

Subutex) and an opioid

• Unwillingness or failure to engage in evidence-based patient

management methods that may include but are not limited to

the following:

o Pain management by a single provider, with all pain

medications prescribed by that provider

o Pain management agreement between the member and

the provider outlining both the provider and member’s

obligations surrounding the prescription, fulfillment, and

management of controlled substances as well as a clear

path of action when said contract is broken

o Periodic drug screening tests

o Attempts to taper controlled substance dosing as medically

appropriate, using appropriate non-controlled drugs and

nonpharmacologic treatments to optimize symptom

management while minimizing controlled substance use

Coding

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N/A

Related Information

Controlled substances are defined and categorized by the Drug Enforcement Administration

(DEA) under classification C1 through C5 (or Schedule I to Schedule V). The categorization is

based upon a substance’s medical use, potential for abuse, and safety or dependence liability.

The medical policy encompasses all controlled substances; given all have potential for abuse; the

data and evidence below are mainly focused on narcotics or opioids for the treatment of chronic

noncancer pain (CNCP).

There are numerous available treatment modalities for CNCP including pharmacologic and non-

pharmacologic interventions. Among these, opioids, known for their strong analgesic properties,

have gained popularity over the past two decades. Their use is established in the setting of

acute, postoperative pain, cancer pain and pain at the end of life. In contrast, the role of opioids

for managing CNCP is controversial, owing to the paucity of high-quality evidence

demonstrating effectiveness and safety in this patient population. Existing data are limited by

suboptimal study designs characterized by largely observational, non-comparative studies,

short-term follow-up and significant withdrawal rates. Two Danish epidemiologic studies

showed that in a region where opioids are prescribed liberally for pain, the patients receiving

opioid analgesics reported worse pain, higher utilization of healthcare, and lower activity levels

compared to matched controls. A population-based cohort study from the same authors

showed the odds of recovery from chronic pain were four times higher in patients not using

opioids, compared with those using opioids for pain management.23,27-29 While opioid analgesics

are indeed effective in some patients, they may not be suitable for all. Therefore it is to the

benefit of patients to constructively address the issue of over-prescribing, over-use, and misuse

of opioid medications. Due to the substantial evidence of increasing morbidity and mortality

associated with prescription opioid use, this medical policy which will guide appropriate use of

controlled substances is necessary.

Opioids produce both analgesia and euphoria. The mood altering action of opioids in addition

to the physical dependence and addictive qualities of this class of drugs encourages abuse

(nonmedical use). Opioid abuse and misuse occurs for a variety of reasons, including self-

medication, use for reward, compulsive use because of addiction, and diversion for profit.27

Individuals with chronic pain and co-occurring substance use disorders and/or mental health

disorders, are at higher risk for misuse of prescribed opioids. The increasing use of opioid

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analgesics for treating chronic noncancer pain, and the introduction of high-dose, extended

release oral tablet formulations of opioids with good bioavailability, has increased opportunities

for the illicit use of prescription opioids. Such use has become a major societal problem,

reaching epidemic proportions; it now exceeds the use of street narcotics in the United States. In

April 2011, the White House unveiled a multi-agency plan aimed at reducing the “epidemic” of

prescription drug abuse in the United States. The plan is a collaborative effort involving various

agencies. According to the director of the White House Office of National Drug Control Policy

(ONDCP) this plan “provides a national framework for reducing prescription drug abuse and the

diversion of prescription drugs for recreational use.” Advocacy for prescribing opioids despite

the lack of long-term effectiveness, unproven standards, and guidelines with conflicting

recommendations, contributes to the epidemic of opioid abuse. Clinical decisions and practice

recommendations must rely to a significant extent on practice experience and consensus rather

than research evidence in assessing the treatment of acute and chronic noncancer pain.

Evidence supporting long-term benefit of opioid analgesics for managing CNCP is lacking,

owing to the predominantly observational and short-term nature of studies. Furthermore, data

comparing various opioids and opioids to other analgesics or to nonpharmacologic modalities

are also lacking. The harms from prescription opioids to patients and others are substantial and

increasingly recognized. When opioids are used, initial risk assessment, careful dose titration and

monitoring including functional outcomes, while educating patients is key. It is also important to

recognize patients at highest risk of adverse events – those receiving high opioid doses and

from multiple providers.

Various guidelines which have been published all agree that prevention of controlled substance

abuse is key. For providers, the ability to identify patients who are most “at-risk” for developing

prescription drug abuse prior to initiation of opioids is critical. Screening patients to determine

their risk of drug abuse prior to beginning opioid therapy is considered standard of practice.27

Several risk factors have been described and include sociodemographic factors, pain and drug-

related factors, genetics and environment, psychosocial and family history, psychopathology,

and alcohol and substance use disorders. It is suggested that the risk of prescription drug abuse

is greatest when risk factors in 3 categories occur in the same individual. In the absence of

psychosocial comorbidities and genetic predisposition, pain patients on stable doses of opioids

in a controlled setting are unlikely to abuse opioids or develop addiction. On the other hand,

patients with a personal or family history of substance abuse, and psychosocial comorbidity, are

at increased risk, especially if treatment with opioids is not carefully structured and monitored

(Ballantyne). Patients who are undergoing chronic opioid therapy for pain have been shown to

have significantly higher Screener and Opioid Assessment for Patients with Pain (SOAPP),

Current Opioid Misuse Measure (COMM), and drug misuse index (DMI) scores (p

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evidence of doctor-shopping were significantly more likely to have a previous history of

overdose, or a history of substance abuse.14 These data suggest that both patients and providers

may benefit from other treatment options before beginning opioid therapy for pain such as

exercise and cognitive behavioral therapy for chronic management.

Indicators of Potential Excessive Use, Misuse, Non-Medical Use, or

Diversion of Controlled Substance

When treatment with controlled medications has already been initiated, identification of

indicators of potential excessive use, misuse, non-medical use, or diversion becomes critical to

preventing or intervening in cases of abuse, addiction, or serious adverse events. Clinical

experience and studies have identified a number of factors that indicate potential excessive use,

misuse, non-medical use, or diversion. There is no factor that is absolutely indicative of excessive

use, misuse, non-medical use; identification of one or more factors requires individual patient

evaluation to differentiate between inappropriate use and possible appropriate use given a

patient’s unique clinical circumstances.23,38

The most common indicators of potential excessive use, misuse, non-medical use, or diversion

are doctor shopping, and high or escalating doses of opioids. These two are widely used

criterion to identify people who may be engaged in non-medical use of controlled substances.

Cantrell et al.35 use the following criteria for identification of ‘doctor shopping’: 2 or more

prescribers within 30 days, greater than 4 during 1 year, and greater than 5 during 1 year.14,15,34

Pradel et al.19 defined doctor shopping as the amount of drug obtained through doctor

shopping compared with the amount intended to be prescribed. The use of “pill mills,” in which

a prescriber provides ready access to prescriptions or pills, can also be considered a form of

doctor shopping.35

Doctor shopping is directly associated with the incidence of deaths from opioids. Hall et al.14

reviewed characteristics of decedents who died of prescription drugs in West Virginia and

reported that opioid analgesics accounted for 93% of deaths. The authors determined the

prescription history of the drug associated with each fatality. Patients who had received

controlled drugs from 5 or more prescribers in the year before death were defined as engaging

in “doctor shopping,” whereas those whose death was not associated with a valid prescription

were considered to have obtained their drugs through “diversion.” Doctor shopping was

associated with 63 (21%) of the fatalities and diversion was associated with 186 (63%) of the

fatalities. Of the 295 total decedents, 279 (95%) had at least 1 indicator of substance abuse, and

those differed according to whether the drug was obtained through diversion or doctor

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shopping. A report from the CDC reported a rise in prescription opioid-related deaths of 68%

between 1999 and 2004. The CDC also studied prescription drug overdoses and found that 10%

of patients seeing multiple doctors and typically involved in drug diversion accounted for 40%

of the overdoses (see figure below). This illustrates that patients are more likely to overdose if

they are seeing multiple doctors or if they are on a high dose of controlled drug.

High or escalating doses of opioids are also associated with a greater incidence of adverse

outcomes, including opioid-related fatal overdoses. In a study24 of 9,940 adults receiving long-

term opioid therapy for chronic noncancer pain, those who received 100mg/day or more of

morphine equivalent had an 8.9 fold increase in overdose risk (95% CI 4.0-19.7). Although there

is not uniform agreement on what constitutes an excessive dose of opioid, there is a general

consensus that doses above 200 mg Morphine Equivalent Dose (MED) total daily dose should be

considered to be excessive.27

In addition to doctor shopping and high or escalating doses, other factors that have been

identified as indicators of potential excessive use, misuse, non-medical use, or diversion include

multiple prescribers of controlled substances, use of multiple pharmacies to fill controlled

substances prescriptions, the number of controlled prescriptions in defined time periods, and

overlapping or concomitant controlled substances prescriptions. Manchikanti et al.24 noted that

available national data overwhelmingly suggest that the increased supply of opioids, high

medical users, doctor shoppers, and patients with multiple comorbid factors contribute to the

majority of fatalities. They observed that on average, patients were exposed to 2 different

opioids and had 3 different opioid prescribers. Braker et al.39 found that a retrospective review of

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payer opioid prescription data and patient charts from a rural family medicine group identified

patients with 3 or more prescriptions (average 8.4; standard deviation = 5.5; range 3-28) from 2

or more providers (average 3.7; SD = 1.8, range 2-10) over a 6-month period. Concurrent use of

nonopioid analgesics, escalating opioid dosage, and number of providers were the best

predictors for adverse events. Findings from other studies are summarized in the table below.

Author Criteria which identified potential abuse

Gonzalez et al.26 Members who received opioid prescriptions from 3 or more prescribers at 3 or more pharmacies in

a 3-month identification period

Sehgal et al.27 Patients with 3 or more prescriptions from 2 or more providers over a 6-month period; concurrent

use of nonopioid analgesics; escalating opioid dosage; and number of providers

Cepeda et al.36 Overlapping or concomitant prescriptions defined as at least 1 day of overlapping dispensing of

prescriptions written by two or more different prescribers at any time during an 18-month period;

Authors concluded that having two or more overlapping prescriptions written by different

prescribers and filled at 3 or more pharmacies differentiates opioids from diuretics and likely

constitutes shopping behavior.

Dunn et al.37 3 or more prescriptions for opioid analgesics in the first 90 days of the episode

Parente et al.2 developed a claims-based method to identify patients who may be misusing

controlled substances and prescribers who may be providing pharmacologic management that

warrants evaluation. They drew data from health insurance claims and used an 11-member

multidisciplinary expert panel to define criteria for identifying controlled substance patterns of

utilization requiring evaluation. The goal in defining the criteria was to have this be widely

applicable to claims databases to identify possible abuse or diversion of controlled substances

by patients or mismanagement by prescribers. The table below outlines the ten patterns that

were most positively associated with identification of a misuse case.

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Additional factors that have been identified as potential indicators of excessive use, misuse, non-

medical use, or diversion include1 frequent early refill requests; altered or forged prescriptions;

multiple reports of misplaced, lost, or stolen medications or prescriptions; insistence on a

specific controlled substance; missing medical appointments except when a controlled

substance refill is expected or needed; increasing symptoms in spite of being on controlled

substances; declining activity or functioning in spite of being on controlled substances; refusal

to try other non-controlled pharmacologic and non-pharmacologic treatments; reports of or

appearing to be intoxicated, somnolent, sedated, or exhibiting withdrawal symptoms; positive

results for controlled medications on drug screening tests when none have been prescribed;

absence of positive results for controlled medications on drug screening tests when they are

being prescribed; concurrent prescriptions for buprenorphine (Suboxone or Subutex) and an

opioid; unwillingness to take medications as prescribed; and unwillingness or failure to engage

in evidence-based patient management methods.

Although most published studies focus on steps that providers can take to identify patients who

are displaying evidence of possible excessive use, misuse, non-medical use, or diversion, a small

but growing literature is establishing evidence of actions that can be taken by health insurance

companies and managed care companies. For example, Gonzalez et al26 studied the impact of a

care coordination intervention by a managed care organization after identification of potential

opioid misuse. Using their database of prescription claims, the organization identified members

who filled controlled opioid medications prescribed by three or more providers and filled at

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three or more pharmacies in a three-month period. Half of these members were randomized to

an intervention arm in which a letter was sent quarterly to the prescriber explaining their patient

was receiving multiple opioid prescriptions filled at multiple locations. They were also sent a

clinical medication report detailing each opioid prescription that was filled by their patient in the

past three months, at which pharmacies, and who the other prescribers were. The prescriber was

encouraged to contact the other prescribers listed in an effort to coordinate care. For members

in the control group, generic letters were sent to the prescriber discussing the importance of

opioid management, but no details or identifying information were given. The members in the

intervention group showed a 24% greater reduction in number of prescribers, 16% greater

reduction in the number of pharmacies used, and a 15% greater reduction in number of

controlled opioid prescriptions compared to the control group. The authors concluded that

managed care organizations have the opportunity to identify potential opioid misuse and

implement care coordination interventions. Additionally the study revealed patients receiving

opioid prescriptions from multiple prescribers and pharmacies during short time intervals is

evidence of uncoordinated pain management and suggests misuse of opioid medications.

Although dependence or addiction to opioid medications cannot be diagnosed by analysis of

prescription claims alone, prescription claims may be used as a tool to guide future prescribing

and to pinpoint factors associated with the uncoordinated care of a member.

One Prescriber Restrictions

Limiting the prescription and management of controlled substances to a single prescriber has

become standard of care for patients receiving chronic treatment for non-cancer disorders. As

noted in the previous section, evidence-based studies have documented a direct relationship

between the number of prescribers of opioids for a patient and the severity of adverse effects

including opioid-related deaths.24,39 Conversely, limiting opioid prescription and management to

a single prescriber significantly reduces the occurrence of severe adverse effects and fatal

outcomes associated with treatment with opioids.40

Systematic reviews of evidence-based treatment guidelines for pain management demonstrate

almost universal agreement that controlled medications should be prescribed and managed by

a single prescribing physician, or a single treatment team for patients who are managed by a

clinic team.41 42 When a patient’s health care is being managed by multiple provides, which is

common, all providers should agree on a single designated prescriber for controlled pain

medications.41

Systematic reviews of evidence-based treatment guidelines have also established the usefulness

of patient-provider agreements, also known as patient contracts, when controlled pain

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medications are utilized for the management of chronic non-cancer pain.41 Reviews of the

specific components of patient-provider agreements have consistently identified the

identification and utilization of a single prescriber of controlled medications as a key component

of such agreements.23,41

A number of prominent provider organizations, concerned about escalating numbers and doses

of opioid prescriptions, have taken steps to limit and prevent excessive use, misuse, non-medical

use, diversion, and adverse outcomes. Group Health Cooperative in Washington state developed

and implemented a comprehensive guideline for chronic opioid therapy for patients with

chronic non-cancer pain. Compliance with the guideline is mandatory for all of Group Health’s

clinicians. Among the stipulations in the guideline is the requirement that for patients taking

opioids for chronic non-cancer pain, each patient’s opioids must be prescribed and managed by

a single physician.43,44

Government agencies have also become increasingly concerned about escalating use of

controlled prescription medications, particularly opioids due to the alarming increase in the

number of deaths from accidental overdoses (BMJ). Various state and Federal agencies have

devised programs targeting excessive use of opioids, including prescription monitoring

programs that allow prescribing clinicians to access databases listing all controlled medications

prescribed to patients. The state of Washington has also issued mandatory rules for the

management of chronic non-cancer pain. Based on the best available evidence, the rules

stipulate, among other provisions, that chronic non-cancer pain patients receive all chronic pain

management prescriptions from one physician.45

Benefit Application

This policy is managed through the Pharmacy benefit.

References

1. Wunsch, M, Boyd, C, McMaster M, “Nonmedical Use of Prescription Medications” in Ries, R, Fiellin, D, Miler, S, Saltz, R, ed.

Principles of Addiction Medicine, 4th edition, Chapter 33, pp 453-467; Lippincott Williams and Wilkins; 2009.

2. Parente, S, Kim, S, Finch, M, et al. Identifying Controlled Substance Patterns of Utilization Requiring Evaluation Using

Administrative Claims Data; Am J Manag Care;10(11):783-790.

3. Federation of State Medical Boards. Model Policy for the Use of Controlled Substances for the Treatment of Pain. May 2004.

4. Drug Utilization Review. Academy of Managed Care Pharmacy, Nov. 2009.

Page | 12 of 14 ∞

5. SAMHSA. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: Substance Abuse

and Mental Health Services Administration; 2007b.

6. US Department of Health and Human Services, substance abuse and mental health services administration. Results from the

2007 national survey on drug use and health: national findings. NSDUH Series H-34, DSHS Publication No. SMA 08-4343.

Rockville, MD: Office of Applied Studies, 2008.

7. Webster, L. Update on Abuse-resistant and abuse-deterrent approaches to opioid formulations. Pain Med 2009;10 Suppl

2:S124-S133.

8. Drug Abuse Warning Network (DAWN): Drug-related emergency department visits for 2004-2009 [online]. Available online:

https://www.samhsa.gov/ Accessed December 2019.

9. Moore TJ, Cohen MR and Furberg CD. Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.

Arch Intern Med 2007;167 (16):1752-1759.

10. Coolen P, Best S, Lima A, et al. Overdose deaths involving prescription opioids among Medicaid enrollees – Washington, 2004-

2007. MMWR 2009;58(42):1171-1175.

11. US Department of Health and Human Services, Substance Abuse and Mental Health Services. Summary report of the meeting:

methadone mortality – a reassessment [online]. Available online:

http://www.samhsa.gov/data/sites/default/files/DAWNMEAnnualReport2010/DAWNMEAnnualReport2010/DAWN-

ME-AnnualReport-2010.pdf Accessed December 2019.

12. Walsh SL, Nuzzo PA, Lofwall MR and Holtman JR. The relative abuse liability of oral oxycodone, hydrocodone, and

hydromorphone assessed in prescription opioid abusers. Drug Alcohol Depend 2008;98(3):191-202.

13. Eriksen J, Sjøgren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an

epidemiological study. Pain. 2006;125(1-2):172–179.

14. Hall AJ, Logan JE, Toblin RL, Kaplan JA, Kraner JC, et al. Patterns of abuse among unintentional pharmaceutical overdose

fatalities. Journal of the American Medical Association. December 2008;300(22):2613–2620.

15. Katz N, Panas L, Kim M, Audet AD, Bilansky A, Eadie J, Kreiner P, Paillard FC, Thomas C, Carrow G. Usefulness of prescription

monitoring programs for surveillance: analysis of Schedule II opioid prescription data in Massachusetts, 1996-2006.

Pharmacoepidemiol Drug Saf 2010;19:115–123.

16. Paulozzi LJ, Kilbourne EM, Shah NG, Nolte KB, Desai HA, Landen MG, Harvey W, Loring L. A History of Being Prescribed

controlled Substances and Risk of Drug Overdose Death. Pain Medicine 2012; 13: 87-95.

17. Paulozzi LJ, Stier DD. Prescription drug laws, drug overdoses, and drug sales in New York and Pennsylvania. J Public Health

Policy 2010;31(4):422-432.

18. Paulozzi LJ, Weisler RH, Patkar AA. A national epidemic of unintentional prescription opioid overdose deaths: how physicians

can help control it. J Clin Psychiatry. 2011;72:589–592.

19. Pradel V, Frauger E, Thirion X, et al. Impact of a prescription monitoring program on doctor-shopping for high dosage

buprenorphine. Pharmacoepidemiol Drug Saf. 2009;18(1):36–43.

20. Prescriptions for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs. Coalition Against

Insurance Fraud: Washington, DC, December 2007:5.

21. RCW 70.255. Prescription Monitoring Program. Washington State Legislature. 2007.

22. Wisley BL, Fishman SM, Gilson AM, Casamalhuapa C, Baxi H, Lin T, Li C. An analysis of the number of multiple prescribers for

opioids utilizing data from the California Prescription Monitoring Program. Pharmacoepidemiol Drug Saf 2011; 20; 1262-1268

23. Fishman, Scott, M., Responsible Opioid Prescribing: A Clinician’s Guide, Second Edition for the Federation of State Medical

Boards (FSMB) Research and Education Foundation, Waterford Life Sciences, Washington, D.C., 2012

24. Manchikanti L, Helm S, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3S):ES9-ES38.

https://www.samhsa.gov/http://www.samhsa.gov/data/sites/default/files/DAWNMEAnnualReport2010/DAWNMEAnnualReport2010/DAWN-ME-AnnualReport-2010.pdfhttp://www.samhsa.gov/data/sites/default/files/DAWNMEAnnualReport2010/DAWNMEAnnualReport2010/DAWN-ME-AnnualReport-2010.pdf

Page | 13 of 14 ∞

25. Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health:

Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and

Mental Health Services Administration, 2012.

26. Gonzalez AM, Kolbasovsky A. Impact of a managed controlled-opioid prescription monitoring program on care coordination.

Am J Managed Care. 2012;18(9):516-524.

27. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies

to curb opioid abuse. Pain Physician. 2012;15(3S):ES67-ES92.

28. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J

Pain. 2006;10:287-333.

29. Eriksen J, Sjogren P, Bruera E, et al. Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain.

2006;125:172-179.

30. Sjogren P, Bronbaek M, Peuckmann V, et al. A population-based cohort study on chronic pain: The role of opioids. Clin J Pain.

2010;26:763-769.

31. Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician

2009;12(3):507-515.

32. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing

behaviors. Ann Emerg Med 2010;56(1):19-23.

33. Savage S, Covington EC, Gilson AM, Gourlay D, Heit HA and Hunt JB. Definitions related to the use of opioids for the treatment

of pain: consensus statement of the American Academy of Pain Medicine, the American Pain Society, and the American Society

of Addiction Medicine. Consensus revision adopted April 2004.

34. Wilsey BL, Fishman SM, Gilson AM, et al. Profiling multiple providers prescribing of opioids, benzodiazepines, stimulants, and

anorectics. Drug Alcohol Dependence. 2010;112:99-106.

35. Cantrill SV, Brown MD, Carlisle RJ, Delaney KA, et al. Clinical Policy: Critical Issues in the prescribing of opioids for adult patients

in the emergency department. Ann Emerge d. 2012;60:499-525.

36. Cepeda MS, Fifd D, Chow W, Mastrogiovanni G and Henderson SC. Assessing Opioid Shopping Behaviour: A Large Cohort

Study from a Medication Dispensing Database in the US. Drug Saf 2012: 35(4):325-334.

37. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, O Merril J, Sullivan MD et al. Overdose and prescribed opioids:

Associations among chronic non-cancer pain patients. Ann Intern Med. 2010 January 19; 152(2):85-92.

38. Smith, HS, Argoff, L, “Chronic Opioid Therapy in Pain Management,” in Ebert, M, Keins, RD, Behavioral and

Psychopharmacologic Pain Management, pp 142-164; Cambridge University Press; 2011.

39. Braker LS, Reese LA, Card RO, and Van Howe RS. Screening for potential prescription misuse in a Michigan Medicaid

population. Family Medicine. 2009; 41 (10): 729-734.

40. Franklin GM. Opioids: A Public Health Emergency. National Summit on Opioid Safety. Group Health Cooperative. Seattle, WA,

November 1, 2011.

41. Hughes MA, Biggs JJ, Thiese MS, et al. Recommended opioid prescribing practices for use in chronic non-malignant pain: a

systematic review of treatment guidelines. Journal of Managed Care Medicine. 2010; 14 (3): 52-58.

42. Von Korff M, Kolodny A, Deyo RA, and Chou R. Long term opioid therapy reconsidered. Annals of Internal Medicine. 2011; 155

(5): 325-328.

43. McCarthy M. Containing the opioid overdose epidemic. BMJ. 2012; 345; e8340.

44. Group Health Cooperative. Chronic Opioid Therapy Safety Guidelines for Patients with Chronic Non-Cancer Pain. 2010-2012.

45. Washington Administrative Code 246-919-856. Pain Management Rules. Washington State Department of Health-Medical

Quality Assurance Commission. Effective January 2, 2012.

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History

Date Comments 10/09/12 New policy added to Prescription Drug section. Policy approved with 90-day provide

notification hold. The policy is effective February 11, 2013.

01/22/13 Policy effective date delayed and is now April 1, 2013.

03/11/13 Replace policy. Policy updated within the Policy Guidelines, clarifying criteria added,

removed and rearranged; Description section removed; Rationale section significantly

updated; references added, removed, renumbered and updated. Policy effective date

remains April 1, 2013.

07/08/13 Minor Update – Clarification was added to the policy that it is managed through the

member’s pharmacy benefit; this is now listed in the header and within the coding

section.

12/08/14 Annual Review. Converted to Benefit Coverage Guideline template. No change in

policy statement.

09/08/15 Annual Review. No change in coverage statements.

11/01/16 Annual Review, approved October 11, 2016. Updated Coverage Guideline sentence.

09/01/17 Annual Review, approved August 22, 2017. No changes to coverage guidelines.

11/01/18 Annual Review, approved October 26, 2018. No changes to coverage guidelines.

01/01/20 Annual Review, approved December 10, 2019. No changes to coverage guidelines.

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.

Discrimination is Against the Law

LifeWise Health Plan of Washington complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. LifeWise does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

LifeWise: • Provides free aids and services to people with disabilities to communicate

effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible

electronic formats, other formats) • Provides free language services to people whose primary language is not

English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that LifeWise has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-6396, Fax 425-918-5592, TTY 800-842-5357 Email AppealsDepartmentInquiries@LifeWiseHealth.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

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 Avenue 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.

Getting Help in Other Languages

This Notice has Important Information. This notice may have important information about your application or coverage through LifeWise Health Plan of Washington. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-592-6804 (TTY: 800-842-5357).

አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ LifeWise Health Plan of Washington ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-592-6804 (TTY: 800-842-5357) ይደውሉ።

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa LifeWise Health Plan of Washington tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-592-6804 (TTY: 800-842-5357) tii bilbilaa.

Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de LifeWise Health Plan of Washington. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez le 800-592-6804 (TTY: 800-842-5357).

Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè LifeWise Health Plan of Washington. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-592-6804 (TTY: 800-842-5357).

Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch LifeWise Health Plan of Washington. 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 800-592-6804 (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 LifeWise Health Plan of Washington. 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 800-592-6804 (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 LifeWise Health Plan of Washington. Daytoy ket mabalin dagiti importante a petsa iti daytoy

(Arabic): ةالعربي 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 امةھ ماتولعم اراإلشع ھذا يحوي . أو طلبك وصخصب مةمھ اتمولعم عارشإلا ھذا ويحي قد

mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga اللخ من ھاعلي لوالحص تريد التي التغطية LifeWise Health Plan of Washington. قدawan ti bayadanyo. Tumawag iti numero nga 800-592-6804 (TTY: 800-842-5357).

على اظلحفل نةعيم يخراوت في إجراء التخاذ اجتحت قدو . اإلشعار ذاھ في مھمة يخراوت ھناك تكون ةدمساعوال تالوملمعا ھذه على ولحصال لك يحق .يفكالتال دفع في دةاعسملل أو يةحصلا تكطيتغ

فةلكت أية بدتك دون تكغلب (TTY: 800-842-5357) 6804-592-800بـصل ات .

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 LifeWise Health Plan of Washington 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 800-592-6804 (TTY: 800-842-5357)。

037336 (07-2016)

Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso LifeWise Health Plan of Washington. 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 800-592-6804 (TTY: 800-842-5357).

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@LifeWiseHealth.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、 LifeWise Health Plan of Washington 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。 800-592-6804 (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 LifeWise Health Plan of Washington 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 . 800-592-6804 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ LifeWise Health Plan of

Washington. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນ້ີ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າ ເນີ ນການຕາມກໍ ານົດເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລ່ື ອງຄ່າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນ້ີ ແລະ ຄວາມ ວຍເຫຼື ອເປັ ນພາສາຂອງທ່ານໂດຍບໍ່ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-592-6804

(TTY: 800-842-5357).

ភាសាែខមរ (Khmer):

ມູ ຮັ ສິ

ມູ ຂໍ້

ສໍ

ຈ່

ວັ

ມູ ຂໍ້ ມີ ໝັ

ຊ່

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Health Plan of Washington. 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 800-592-6804 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через LifeWise Health Plan of Washington. 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 800-592-6804 (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, LifeWise Health Plan of Washington, 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 800-592-6804 (TTY: 800-842-5357).

Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Health Plan of Washington. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de

េសចកតជី ូ នដំ ងេនះមានព័ ី

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់ តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ជូ ត៌ ណឹ នដ

រងរបស់អន

LifeWise Health Plan of Washington ។ របែហលជាមាន កាលបរ ិ ឆ ំ ់ េចទសខានេនៅ

មានយ៉ា ំ ់ ត ងសខាន។ េសចក ំណឹងេនះរបែហល

កតាមរយៈ

ងេសចកត ី នដណងេនះ។ អករបែហលជារតវការបេញញសមតភាព ដល់ ណត់ ំ ឹ ន ូ ច ថ កំ ជូ កន ុ determinadas fechas para mantener su cobertura médica o ayuda con los អន ៃថងជាកចបាសនានា េដ ី ឹ ុ ៉ ប់ ុខភាពរបស់ ក ឬរបាក់ costos. Usted tiene derecho a recibir esta información y ayuda en su idioma ់ ់ ើមបនងរកសាទកការធានារា រងស

ក sin costo alguno. Llame al 800-592-6804 (TTY: 800-842-5357). ជ ំ យេចញៃថ កមានសិ េដាយមិ ុ ើ ូ ូ នអសលយេឡយ។ សមទ

ទធ នួ ល។ អន នួ ិ ួលព័ ៌ ិងជំ ន ុងភាសារបស ទទ តមានេនះ ន យេនៅក អន ់

800-592-6804 (TTY: 800-842-5357)។

រស័

ਅੰ

ਜਾਬੀ (Punjabi): paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋ ਿਟਸ ਿਵਚ LifeWise Health Plan of tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng LifeWise

Health Plan of Washington. Maaaring may mga mahalagang petsa dito sa Washington ਵਲ ਤੁ ਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹਤਵਪੂ ੋ ਸਕਦੀ ਹਾਡੀ ਕਵਰੇ ੱ ਰਨ ਜਾਣਕਾਰੀ ਹ

ពទ

paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang ਹੈ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਂ ਹਨ. ਜੇ ੁ ੇ ੱ ਖਣੀ ਹੋ ੇ mga itinakdang panahon upang mapanatili ang iyong pagsakop sa . ਇਸ ਨ ਸਕਦੀਆ ਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰ ਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ੱ ੁ ੋ ਤਾਂ ਤੁ ੰ ੂ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ਇਛਕ ਹ ਹਾਨ ੱ ਝ ਖਾਸ

ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag ਕਦਮ ਚੁਕਣ ਦੀ ਲੜ ਹੋ ਸਕਦੀ ਹ ੈ,ਤੁ ੰ ੂ ਮੁ ੱ ਚ ਤੇ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ੱ ੋ ਹਾਨ ਫ਼ਤ ਿਵ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਮਦਦ sa 800-592-6804 (TTY: 800-842-5357). ਪ੍ਰ ੈਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-592-6804 (TTY: 800-842-5357).

ਪੰ

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang

ไทย (Thai): ประกาศน ้ีมีข้อมลูสําคญั ประกาศน ้ีอาจมีข้อมลูที่สําคญัเกี่ยวกบัการการสมคัรหรือขอบเขตประกนั

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

สขุภาพของคณุผ่าน LifeWise Health Plan of Washington และอาจมีกําหนดการในประกาศ طريق از ماش ای مهبي وششپ يا و تقاضا LifeWise Health Plan of Washington به .باشدี น جهتو يهمالعا اين در ھمم ھای خيتار يا تان بيمه وششپ حقظ برای است کنمم ماش . يدماين کمک คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกนัสขุภาพของคณุ

اجتياح صیاخ کارھای امانج برای صیمشخ ھای خيتار به تان، انیمدر ھای زينهھ پرداخت درหรือการช่วยเหลือที่มีค่าใช้จ่าย คณุมีสิทธิที่จะได้รับข้อมลูและความช่วยเหลือน ้ีในภาษาของคณุโดยไม่ม ีباشيد داشته . رايگان ورط به ودخ انزب به را مکک و اطالعات اين که داريد را اين حق ماش

(ค่าใช้จ่าย โทร 800-592-6804 (TTY: 800-842-5357 مارهش با اطالعات سبک برای . نماييد دريافت 800-592-6804 . اييد نم برقرار استم ) 5357-842-800 مارهباش اس تم TTY کاربران(

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