* ES MB mPA PA Rx Rx,MB SI

Indicates Limited Distribution products distributed by CVS Specialty. Indicates Limited Distribution products not distributed by CVS Specialty. Delivered through the CareFirst Exclusive Specialty Pharmacy network. Covered under medical benefit. Prior authorization required for medical benefits coverage. Prior authorization required for prescription benefits coverage. Covered under prescription benefit. May be covered under either prescription or medical benefits. Please consult your plan to determine coverage. Self-injectable product.

Specialty Drugs (effective October 1, 2017) Specialty drugs are high-cost, prescription drugs used to treat serious or chronic medical conditions and require special handling (such as refrigeration), administration or monitoring. The following is a list of specialty drugs that may be covered through either your prescription or medical plan; however other specialty drugs may also be covered. To learn more about your specific drug benefit or to use the Drug Cost Tool, log in to My Account at www.carefirst.com/myaccount and click on Drug & Pharmacy Resources under Quick Links or call CareFirst Pharmacy Services at 800-241-3371. This list represents brand products in CAPS and generic products in lowercase italics.

SPECIALTY DRUGS ACROMEGALY octreotide acetate

(SANDOSTATIN) Rx,MB ES PA SI SANDOSTATIN LAR MB mPA SIGNIFOR LAR MB SOMATULINE DEPOT MB mPA SOMAVERT * Rx,MB ES PA SI ALCOHOL / OPIOID DEPENDENCY VIVITROL MB ALLERGEN IMMUNOTHERAPY ORALAIR * Rx ALLERGIC ASTHMA CINQAIR * MB NUCALA * MB XOLAIR * MB mPA ALPHA-1 ANTITRYPSIN DEFICIENCY ARALAST NP * MB mPA GLASSIA * MB mPA PROLASTIN-C MB mPA ZEMAIRA * MB mPA AMYOTROPHIC LATERAL SCLEROSIS RADICAVA MB mPA ANEMIA ARANESP Rx,MB ES PA SI EPOGEN Rx,MB ES PA SI MIRCERA Rx,MB PA SI PROCRIT Rx,MB ES PA SI ATOPIC DERMATITIS DUPIXENT Rx ES PA SI BATTEN DISEASE BRINEURA MB mPA BOTULINUM TOXINS BOTOX MB mPA DYSPORT MB mPA MYOBLOC MB mPA XEOMIN * MB mPA

CARDIAC DISORDERS dofetilide (TIKOSYN) Rx ES PA NORTHERA * Rx ES PA COAGULATION DISORDERS CEPROTIN * MB CONTRACEPTIVES KYLEENA MB LILETTA MB MIRENA * MB NEXPLANON * MB SKYLA * MB CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ARCALYST * Rx,MB ES PA SI ILARIS * MB mPA KINERET Rx,MB ES PA SI CUSHINGS SYNDROME KORLYM Rx PA SIGNIFOR Rx,MB PA SI CYSTIC FIBROSIS BETHKIS * Rx,MB ES PA CAYSTON Rx,MB PA KALYDECO Rx PA KITABIS PAK Rx,MB ES PA ORKAMBI Rx PA PULMOZYME Rx,MB ES PA TOBI PODHALER * Rx,MB ES PA tobramycin inhalation solution

(TOBI) Rx,MB ES PA DUCHENNE MUSCULAR DYSTROPHY EMFLAZA Rx PA EXONDYS 51 MB DUPUYTRENS CONTRACTURE XIAFLEX MB ELECTROLYTE DISORDERS SAMSCA Rx ES PA STRENSIQ Rx,MB PA

GASTROINTESTINAL DISORDERS-OTHER CHOLBAM Rx PA GATTEX * Rx,MB ES PA SI OCALIVA Rx ES PA XERMELO Rx PA GOUT KRYSTEXXA MB GROWTH HORMONE & RELATED DISORDERS Growth Hormone Disorders GENOTROPIN Rx,MB ES PA SI HUMATROPE Rx,MB ES PA SI NORDITROPIN Rx,MB ES PA SI NUTROPIN AQ Rx,MB ES PA SI OMNITROPE Rx,MB ES PA SI SAIZEN Rx,MB ES PA SI SEROSTIM * Rx,MB ES PA SI TEV-TROPIN Rx,MB ES PA SI ZOMACTON Rx,MB ES PA SI ZORBTIVE Rx,MB ES PA SI IGF-1 Deficiency INCRELEX * Rx,MB ES PA SI HEMATOPOIETICS MOZOBIL * MB HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BLEEDING DISORDERS ADVATE MB mPA ADYNOVATE * MB AFSTYLA MB ALPHANATE MB mPA ALPHANINE SD MB mPA ALPROLIX MB mPA BEBULIN MB mPA BENEFIX MB mPA COAGADEX MB CORIFACT * MB ELOCTATE MB mPA FEIBA NF MB mPA FEIBA VH MB mPA HELIXATE FS MB mPA HEMOFIL M MB mPA HUMATE-P MB mPA IDELVION MB

* ES MB mPA PA Rx Rx,MB SI

Indicates Limited Distribution products distributed by CVS Specialty. Indicates Limited Distribution products not distributed by CVS Specialty. Delivered through the CareFirst Exclusive Specialty Pharmacy network. Covered under medical benefit. Prior authorization required for medical benefits coverage. Prior authorization required for prescription benefits coverage. Covered under prescription benefit. May be covered under either prescription or medical benefits. Please consult your plan to determine coverage. Self-injectable product.

IXINITY MB KOATE-DVI MB mPA KOGENATE FS MB mPA KOVALTRY MB MONOCLATE-P MB mPA MONONINE MB mPA NOVOEIGHT MB NOVOSEVEN RT MB mPA NUWIQ MB OBIZUR * MB PROFILNINE SD MB mPA RECOMBINATE MB mPA RIASTAP MB RIXUBIS MB mPA STIMATE MB TRETTEN * MB VONVENDI MB WILATE MB mPA XYNTHA MB mPA HEPATITIS C DAKLINZA Rx ES PA EPCLUSA Rx ES PA HARVONI Rx ES PA INTRON A * Rx,MB ES PA SI MAVYRET Rx ES PA OLYSIO Rx ES PA PEGASYS Rx,MB ES PA SI REBETOL SOLUTION Rx ES PA RIBAPAK Rx ES PA RIBASPHERE Rx ES PA ribavirin caps (REBETOL) Rx ES PA ribavirin tabs

(COPEGUS, MODERIBA) Rx ES PA SOVALDI Rx ES PA TECHNIVIE Rx ES PA VIEKIRA PAK Rx ES PA VIEKIRA XR Rx ES PA VOSEVI Rx ES PA ZEPATIER Rx ES PA HEREDITARY ANGIOEDEMA BERINERT * Rx,MB ES PA mPA SI CINRYZE * Rx,MB ES PA mPA SI FIRAZYR * Rx,MB ES PA SI HAEGARDA Rx ES PA SI KALBITOR * Rx,MB ES PA mPA SI RUCONEST * Rx,MB ES PA SI HEREDITARY TYROSINEMIA NITYR Rx PA ORFADIN Rx PA HIV MEDICATIONS EGRIFTA * Rx,MB ES PA SI FUZEON Rx ES PA SI HORMONAL THERAPIES AVEED * MB ELIGARD MB mPA FIRMAGON MB mPA H.P. ACTHAR GEL * Rx,MB ES PA mPA SI leuprolide acetate (LUPRON) Rx,MB ES PA SI

LUPANETA PACK MB LUPRON DEPOT MB mPA NATPARA * Rx,MB PA SI SUPPRELIN LA * MB TRELSTAR MB mPA VANTAS MB mPA ZOLADEX MB mPA IMMUNE DEFICIENCIES & RELATED DISORDERS ADAGEN MB mPA BIVIGAM * MB mPA CARIMUNE NF MB mPA CUVITRU MB CYTOGAM MB mPA FLEBOGAMMA DIF MB FLEBOGAMMA MB mPA GAMASTAN S/D MB mPA GAMMAGARD LIQUID MB mPA GAMMAGARD S/D MB mPA GAMMAKED MB mPA GAMMAPLEX * MB mPA GAMUNEX-C MB mPA HEPAGAM B MB HIZENTRA * MB mPA HYPERHEP B MB HYPERRHO S/D MB HYQVIA MB MICRHOGAM MB NABI-HB MB OCTAGAM * MB mPA PRIVIGEN * MB mPA RHOGAM MB RHOPHYLAC MB VARIZIG * MB WINRHO SDF MB IMMUNE (IDIOPATHIC) THROMBOCYTOPENIC PURPURA NPLATE MB mPA PROMACTA * Rx ES PA INFECTIOUS DISEASE ACTIMMUNE * Rx,MB ES PA SI ALFERON N * MB INFERTILITY BRAVELLE Rx,MB SI CETROTIDE Rx,MB SI chorionic gonadotropin

(NOVAREL, PREGNYL) Rx,MB SI FOLLISTIM AQ Rx,MB SI GANIRELIX Rx,MB SI GONAL-F Rx,MB SI MENOPUR Rx,MB SI OVIDREL Rx,MB SI REPRONEX Rx,MB SI INFLAMMATORY BOWEL DISEASE CIMZIA Rx,MB ES PA mPA SI ENTYVIO MB mPA HUMIRA Rx ES PA SI INFLECTRA MB mPA

REMICADE MB mPA SIMPONI Rx,MB ES PA SI STELARA Rx,MB ES PA mPA SI TYSABRI * MB mPA IRON OVERLOAD deferoxamine (DESFERAL) MB EXJADE * Rx ES PA FERRIPROX Rx PA JADENU * Rx PA LIPID DISORDERS JUXTAPID Rx PA KYNAMRO * Rx,MB ES PA SI LIPID DISORDERS - PCSK9 INHIBITORS PRALUENT Rx ES PA SI REPATHA Rx ES PA SI LYSOSOMAL STORAGE DISORDERS ALDURAZYME * MB mPA CERDELGA * Rx ES PA CEREZYME * MB mPA CYSTAGON * Rx ES PA CYSTARAN Rx PA ELAPRASE * MB mPA ELELYSO * MB mPA FABRAZYME * MB mPA KANUMA MB LUMIZYME * MB mPA NAGLAZYME * MB mPA PROCYSBI Rx PA VIMIZIM * MB mPA VPRIV * MB mPA ZAVESCA Rx PA LIPODYSTROPHY MYALEPT Rx,MB PA SI MOVEMENT DISORDERS APOKYN * Rx ES PA SI AUSTEDO Rx PA DUOPA MB INGREZZA Rx PA NUPLAZID * Rx ES PA tetrabenazine (XENAZINE) * Rx ES PA MULTIPLE SCLEROSIS AMPYRA * Rx ES PA AUBAGIO * Rx ES PA AVONEX Rx,MB ES PA SI BETASERON Rx,MB ES PA SI EXTAVIA Rx,MB ES PA SI GILENYA Rx ES PA glatiramer acetate

(COPAXONE) Rx,MB ES PA SI LEMTRADA * MB mPA OCREVUS MB ES mPA PLEGRIDY * Rx,MB ES PA SI REBIF Rx,MB ES PA SI TECFIDERA * Rx ES PA TYSABRI * MB mPA ZINBRYTA * Rx ES PA SI

* ES MB mPA PA Rx Rx,MB SI

Indicates Limited Distribution products distributed by CVS Specialty. Indicates Limited Distribution products not distributed by CVS Specialty. Delivered through the CareFirst Exclusive Specialty Pharmacy network. Covered under medical benefit. Prior authorization required for medical benefits coverage. Prior authorization required for prescription benefits coverage. Covered under prescription benefit. May be covered under either prescription or medical benefits. Please consult your plan to determine coverage. Self-injectable product.

NEUTROPENIA GRANIX Rx,MB ES PA mPA SI LEUKINE Rx,MB ES PA mPA SI NEULASTA Rx,MB ES PA SI NEUPOGEN Rx,MB ES PA mPA SI ZARXIO Rx,MB ES PA SI ONCOLOGY - INJECTABLE ABRAXANE MB mPA ADCETRIS * MB ALIMTA MB mPA ARZERRA * MB AVASTIN * MB mPA azacitidine (VIDAZA) Rx,MB ES PA SI BAVENCIO MB BELEODAQ * MB BENDEKA * MB mPA BESPONSA MB BLINCYTO * MB CYRAMZA * MB DARZALEX * MB decitabine (DACOGEN) * MB ELSPAR * MB EMPLICITI * MB ERBITUX * MB mPA ERWINAZE MB EVOMELA * MB FOLOTYN * MB FUSILEV * MB GAZYVA * MB GEMZAR MB mPA HALAVEN * MB HERCEPTIN * MB mPA IMFINZI MB IMLYGIC MB INTRON A * Rx,MB ES PA SI ISTODAX * MB IXEMPRA * MB JEVTANA * MB KADCYLA * MB mPA KEYTRUDA * MB KYPROLIS * MB LARTRUVO MB levoleucovorin calcium (FUSILEV) * MB LEVOLEUCOVORIN CALCIUM * MB mitoxantrone (NOVANTRONE) * MB ONCASPAR * MB ONIVYDE MB OPDIVO * MB oxaliplatin MB mPA PERJETA * MB mPA PORTRAZZA * MB PROLEUKIN * MB PROVENGE MB mPA RITUXAN HYCELA MB RITUXAN * MB mPA SYLATRON * Rx,MB ES PA SI SYLVANT MB SYNRIBO MB TAXOTERE MB mPA TECENTRIQ MB TEMODAR MB TEPADINA MB THYROGEN * MB

TORISEL * MB TREANDA * MB mPA UNITUXIN MB VALSTAR * MB VECTIBIX * MB VELCADE * MB mPA VYXEOS MB XGEVA MB mPA YERVOY * MB mPA YONDELIS * MB ZALTRAP * MB zoledronic acid (ZOMETA) MB mPA ONCOLOGY - ORAL / TOPICAL AFINITOR Rx ES PA ALECENSA * Rx ES PA ALUNBRIG Rx ES PA bexarotene (TARGRETIN) Rx ES PA BOSULIF Rx ES PA CABOMETYX * Rx ES PA capecitabine (XELODA) Rx ES PA CAPRELSA Rx PA COMETRIQ Rx PA COTELLIC * Rx ES PA ERIVEDGE * Rx ES PA FARYDAK * Rx PA GILOTRIF Rx PA HYCAMTIN * Rx ES PA IBRANCE * Rx ES PA ICLUSIG Rx PA IDHIFA Rx ES PA imatinib (GLEEVEC) Rx ES PA IMBRUVICA Rx PA INLYTA * Rx ES PA IRESSA * Rx PA JAKAFI * Rx ES PA KISQALI FEMARA CO-PACK Rx ES PA KISQALI Rx ES PA LENVIMA Rx PA LONSURF Rx ES PA LYNPARZA Rx PA MEKINIST * Rx ES PA NERLYNX Rx ES PA NEXAVAR * Rx ES PA NINLARO * Rx ES PA ODOMZO Rx ES PA POMALYST * Rx ES PA PURIXAN * Rx REVLIMID * Rx ES PA RUBRACA Rx ES PA RYDAPT Rx ES PA SPRYCEL Rx ES PA STIVARGA * Rx ES PA SUTENT Rx ES PA TAFINLAR * Rx ES PA TAGRISSO * Rx PA TARCEVA * Rx ES PA TARGRETIN GEL Rx ES PA TASIGNA Rx ES PA temozolomide (TEMODAR) Rx ES PA THALOMID Rx ES PA TYKERB * Rx ES PA VALCHLOR Rx PA VENCLEXTA Rx PA

VISTOGARD Rx VOTRIENT * Rx ES PA XALKORI * Rx ES PA XTANDI * Rx ES PA ZEJULA Rx PA ZELBORAF * Rx ES PA ZOLINZA Rx ES PA ZYDELIG Rx PA ZYKADIA * Rx ES PA ZYTIGA Rx ES PA OSTEOARTHRITIS EUFLEXXA MB mPA GEL-ONE MB mPA GELSYN-3 MB mPA GENVISC 850 * MB mPA HYALGAN MB mPA HYMOVIS MB mPA MONOVISC MB mPA ORTHOVISC MB mPA SUPARTZ FX MB mPA SYNVISC ONE MB mPA SYNVISC MB mPA OSTEOPOROSIS FORTEO Rx,MB ES PA SI PROLIA MB mPA TYMLOS Rx ES PA SI zoledronic acid (RECLAST) MB mPA PAIN MANAGEMENT PRIALT MB PAROXYSMAL NOCTURNAL HEMOGLOBINURIA SOLIRIS * MB mPA PHENYLKETONURIA KUVAN * Rx ES PA PRE-TERM BIRTH MAKENA * MB PSORIASIS COSENTYX * Rx,MB ES PA SI ENBREL Rx ES PA SI HUMIRA Rx ES PA SI INFLECTRA MB mPA OTEZLA * Rx ES PA OTREXUP Rx,MB ES PA SI RASUVO Rx,MB ES PA SI REMICADE MB mPA SILIQ Rx ES PA SI STELARA Rx,MB ES PA mPA SI TALTZ * Rx ES PA SI TREMFYA Rx ES PA SI PULMONARY ARTERIAL HYPERTENSION ADCIRCA Rx ES PA ADEMPAS * Rx ES PA epoprostenol sodium (FLOLAN) MB mPA LETAIRIS * Rx ES PA

* ES MB mPA PA Rx Rx,MB SI

Indicates Limited Distribution products distributed by CVS Specialty. Indicates Limited Distribution products not distributed by CVS Specialty. Delivered through the CareFirst Exclusive Specialty Pharmacy network. Covered under medical benefit. Prior authorization required for medical benefits coverage. Prior authorization required for prescription benefits coverage. Covered under prescription benefit. May be covered under either prescription or medical benefits. Please consult your plan to determine coverage. Self-injectable product.

OPSUMIT * Rx ES PA ORENITRAM * Rx ES PA REMODULIN * MB mPA sildenafil (REVATIO) Rx ES PA TRACLEER * Rx ES PA TYVASO * Rx,MB ES PA UPTRAVI Rx ES PA VELETRI * MB mPA VENTAVIS * Rx,MB ES PA PULMONARY DISORDERS-OTHER ESBRIET * Rx ES PA OFEV Rx PA RENAL DISEASE SENSIPAR Rx ES PA RESPIRATORY SYNCYTIAL VIRUS SYNAGIS MB mPA RETINAL DISORDERS EYLEA * MB mPA ILUVIEN * MB

LUCENTIS * MB mPA MACUGEN * MB OZURDEX * MB RETISERT * MB VISUDYNE * MB RHEUMATOID ARTHRITIS ACTEMRA * Rx,MB ES PA mPA SI CIMZIA Rx,MB ES PA mPA SI ENBREL Rx ES PA SI HUMIRA Rx ES PA SI INFLECTRA MB mPA KEVZARA Rx ES PA SI KINERET Rx,MB PA SI ORENCIA Rx,MB ES PA mPA SI OTREXUP Rx,MB ES PA SI RASUVO Rx,MB ES PA SI REMICADE MB mPA SIMPONI ARIA MB mPA SIMPONI Rx,MB ES PA SI XELJANZ XR Rx ES PA XELJANZ Rx ES PA

SEIZURE DISORDERS H.P. ACTHAR GEL * Rx,MB ES PA mPA SI SABRIL * Rx ES PA SLEEP DISORDERS HETLIOZ Rx PA SPINAL MUSCULAR ATROPHY SPINRAZA MB mPA SYSTEMIC LUPUS ERYTHEMATOSUS BENLYSTA SC Rx ES PA SI BENLYSTA MB mPA TRANSPLANT CUVITRU MB UREA CYCLE DISORDERS CARBAGLU Rx PA RAVICTI * Rx ES PA sodium phenylbutyrate (BUPHENYL) Rx ES PA

For CVS Specialty , please call (855) 264-3237.

Products distributed by CVS Specialty, as well as products covered by a plan member's prescription or medical benefit plan may change from time to time. In addition, a plan member's specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association.

Registered trademark of CareFirst of Maryland, Inc.

2017. All rights reserved. SUM2654-1P (10/01/17)

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten 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 interpretersInformation written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst 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 our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

Email Address civilrightscoordinator@carefirst.com

Telephone Number 410-528-7820 Fax Number 410-505-2011

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 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

NDLA (6/17)

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

855-258-6518 0

d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti

gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb

gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh. Qu v c quyn nhn

c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh vin nn gi s in thoi

mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho

n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

kt ni vi mt thng dch vin.

Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

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identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

at ikokonekta ka sa isang interpreter.

Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

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nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

(Russian) !

. ,

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(Hindi) : - 855-258-6518 0 ,

s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k

ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-

kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa

I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke

na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin

ke ni wuu mu za.

(Bengali) : 855-258-6518 0

: (Urdu )

0 6518-258-855

: . (Farsi ). .

.

. 0 855-258-6518

.

: (Arabic) . .

.

.0 855-258-6518

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(Traditional Chinese)

855-258-6518

0

Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d

mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere

ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo

ass chr, a ga-ejik g na onye kwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem

Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)

employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.

(Korean) : . .

. ID .

855-258-6518 0 .

.

(Navajo)

855-258-6518

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