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

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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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(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 .

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037336 (07-2016)

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

้

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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).

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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(

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez LifeWise Health Plan of Washington. 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 800-592-6804 (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 LifeWise Health Plan of Washington. 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 esta informação e ajuda em seu idioma e sem custos. Ligue para 800-592-6804 (TTY: 800-842-5357).

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