Plan 250 Cost Sharing Amounts In-Network
Out-of-Network
Single Participation
Or an individual family member $250
$500
Coinsurance maximum
$1,000
$2,000
Out-of-pocket maximum
$1,250
$2,500
Deductible amount
SelectChoice An overview of benefits and services provided by this plan.
Single Plus Dependent Participation Individual plus eligible children
$375
$750
Coinsurance maximum
$1,500
$3,000
Out-of-pocket maximum
$1,875
$3,750
Deductible amount
Family Participation $500
$1,000
Coinsurance maximum
$2,000
$4,000
Out-of-pocket maximum
$2,500
$5,000
Deductible amount
This chart reflects the cost sharing amounts for each benefit period. In-network and out-of-network amounts accumulate jointly. Outpatient prescription drug cost sharing amounts do not apply to the out-of-pocket maximum.
Outpatient Prescription Drug Coinsurance Maximum Amount
$1,000 per member per benefit period
When the prescription drug coinsurance maximum amount has been met, copayment amounts will continue to apply, and formulary drugs will be covered at 100% of the allowed charge for the remainder of the benefit period. Copayment amounts and the nonformulary sanction do not apply to this coinsurance maximum.
Annual Enrollment Period If an eligible employee or eligible dependent does not apply when first eligible, they may apply during the annual enrollment period. See the benefit plan for special enrollment provisions.
This grid describes what the Plan Administrator believes to be a “grandfathered health plan” under the Patient Protection and Affordable Care Act (Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Subscriber’s Benefit Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any Cost Sharing Amounts. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to BCBSND at the telephone number and address on the back of the Member’s Identification Card. If this Benefit Plan is affected by ERISA, the Member may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. Members may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.
This health plan is that of your employer. Blue Cross Blue Shield of North Dakota is serving only as the Claims Administrator and does not assume any financial risk except for stop-loss coverage.
Call toll-free 1-800-247-3876 www.BCBSND.com
For premium rates and further details of the coverage, including definitions; exclusions; criteria for medically appropriate and necessary care; credentialing process; confidentiality policy; description of experimental drugs, medical devices or treatments; grievance and appeals process; provider listings; drugs eligible for coverage; reductions or limitations; and the terms under which this benefit plan may be continued, see your Account Executive or write to Blue Cross Blue Shield of North Dakota. RW18
Effective 1-1-2018
29378128 9-17
This is a grandfathered Benefit Plan under the Patient Protection and Affordable Care Act (PPACA).
This benefit plan covers these services and more.
Description of Benefits
• Children under age 26. Coverage will be continued until the end of the month in which the child becomes age 26. • Children placed with you or your covered spouse for adoption or whom you or your covered spouse have legally adopted. • Children for whom you or your covered spouse have been appointed legal guardian by court order. • Grandchildren of yours or your covered spouse if: • The parent of the grandchild is unmarried. • The parent of the grandchild is a covered eligible dependent.
In-Network
or out-of-network with an authorized referral
Amounts are a % of the allowed charge after the deductible is met.
Who is eligible for benefits? If you have family coverage, benefits are available for you, your spouse and eligible children. If you have single plus dependent coverage, you and your eligible children are covered. Eligible children include:
Copayment Amount you pay per visit
Inpatient Hospital Services Outpatient Hospital Services
Out-of-Network
Amounts are a % of the allowed charge after the deductible is met.
Before out-of-pocket After out-of-pocket Before out-of-pocket After out-of-pocket maximum is met maximum is met maximum is met maximum is met 90%
100%
80%
100%
90%
100%
80%
100%
• Children incapable of self-support because of an intellectual disability or a physical handicap that began before they reached 26 years of age and who are primarily dependent on you or your covered spouse.
Outpatient prescription drug benefits. This benefit plan includes a preferred pharmacy network. When you use this national network, your claims are filed for you. Participating pharmacists also use a computer database to: • Check for possible interactions between prescriptions. • Find any drug duplications. • Identify overuse or underuse of your medication.
$20
80%
100%
80%
100%
Benefits are based on the medical guidelines established by Blue Cross Blue Shield of North Dakota. Deductible does not apply in-network.
Occupational & Speech Therapy
$20
80%
100%
80%
100%
Benefits are available for 90 consecutive calendar days per condition beginning on the date of the 1st therapy treatment for the condition. Additional benefits may be allowed after the 90 days when medically appropriate and necessary. Deductible does not apply in-network.
90%
100%
80%
100%
Professional Health Care Provider Services Inpatient, Outpatient & Surgical Services
Wellness Services Well Child Care (to member’s 6th birthday)
$25
100%
100%
no coverage
no coverage
Deductible does not apply.
Preventive Screening Services (members 6 and older)
$25
100%
100%
no coverage
no coverage
Maximum benefit allowance of $200 per member per benefit period. Benefits beyond the maximum benefit allowance will be subject to cost sharing amounts. Deductible does not apply.
Immunizations
100%
100%
100%
100%
Deductible does not apply.
Mammography, Pap Smear, Fecal Occult Blood Testing & Prostate Cancer Screening Services
100%
100%
80%
100%
The number of visits for these services may vary by age group. Refer to the benefit plan for details. Deductible does not apply to these services in-network.
90%
100%
80%
100%
Deductible does not apply in-network.
Lab, X-ray, MRI
90%
100%
80%
100%
Allergy Testing
80%
100%
80%
100%
90%
100%
80%
100%
90%
100%
80%
100%
Deductible does not apply for pre and postnatal care.
100% / 90%
100%
100% / 80%
100%
Preauthorization may be required. Refer to the benefit plan for details.
Home & Office Visits Diagnostic Services
$25
Radiation Therapy, Chemotherapy & Dialysis Maternity Services Inpatient, Outpatient, Pre & Postnatal Care
Psychiatric & Substance Abuse Services Inpatient, Partial Hospitalization, Intensive Outpatient Program, Residential Treatment & Outpatient Services
• Determine if a generic equivalent is available for your prescription drug and if the medication appears on a list of quality and cost-effective drugs. Drugs on this list, called formulary drugs, are covered at the maximum benefit amount.
Emergency Services
Prescription drugs are categorized as formulary, nonformulary, nonpayable or restricted-use drugs. A restricted-use drug may have a dispensing limit and/or require prior approval.
Urgent Care Services
Benefits are available nationwide at any pharmacy participating in the preferred pharmacy network. To locate a participating pharmacy, call the special toll-free number listed on the back of your ID card.
Ambulance Services Skilled Nursing Facility Services Home Health Care Services Hospice Services Chiropractic Services
When a generic drug is available but not accepted, the member is responsible for the difference between the cost of the generic and brand name drug. Prescriptions filled at a nonparticipating pharmacy must be paid in full and a paper claim submitted. All costs above the allowance are the member’s responsibility.
Preauthorization may be required.
Physical Therapy
• The parent is primarily dependent on you for their support. • Children for whom you or your covered spouse are required by court order to provide health benefits.
Special Conditions
with a participating BCBSND provider
90%
100%
90%
100%
Preauthorization is not required. In-network deductible applies.
Professional Health Care Provider Visit
$25
90%
100%
90%
100%
Deductible does not apply to the office or emergency room visit.
Emergency Room Charge
$75
90%
100%
90%
100%
Deductible does not apply.
90%
100%
80%
100%
Urgent care services received out-of-network will be reimbursed at the out-of-network level, except when the member is outside the geographic area of their affiliated network. Refer to the benefit plan for details.
Professional Health Care Provider Visit
$25
90%
100%
80%
100%
Emergency Room Charge
$75
90%
100%
80%
100%
80%
100%
80%
100%
In-network deductible applies.
80%
100%
80%
100%
Preauthorization is required.
80%
100%
80%
100%
Preauthorization is required.
80%
100%
80%
100%
Preauthorization is required. In-network deductible applies.
Home & Office Visits
$25
90%
100%
80%
100%
Deductible does not apply when seeing a BCBSND participating chiropractor.
Therapy & Manipulations
$20
80%
100%
80%
100%
Deductible does not apply when seeing a BCBSND participating chiropractor.
90%
100%
80%
100%
80%
100%
80%
100%
Diagnostic Services
Medical Supplies & Equipment Tobacco Cessation Services Related Office Visit
Description of Benefits
Prescription and payable over-the-counter tobacco cessation medications or drugs obtained with a prescription order are paid under the Outpatient Prescription Medications or Drugs benefit below. Refer to the benefit plan for details. $25
90%
100%
Copayment
80%
100%
Benefit Amount
Deductible does not apply in-network.
Special Conditions
Before prescription drug coinsurance maximum is met
After prescription drug coinsurance maximum is met
Outpatient Prescription Medications or Drugs Retail Pharmacy Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Preferred Mail Order Pharmacy
Preferred Specialty Pharmacy This benefit grid presents a brief overview of covered services and payment levels of this product. It should not be used to determine whether your health care expenses will be paid. The written benefit plan governs the benefits available.
One copayment amount per prescription order or refill for a 34-day supply. Two copayment amounts per prescription order or refill for a 35-60 day supply. Three copayment amounts per prescription order or refill for a 61-100 day supply. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply. Two copayment amounts per prescription order or refill for a 61-100 day supply. Mail order prescriptions must be received from the preferred mail order pharmacy. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply. One copayment amount per prescription order or refill for a 34-day supply. Two copayment amount per prescription order or refill for a 35-100 day supply. Specialty Drugs must be received from the preferred specialty pharmacy network. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply.
This benefit plan covers these services and more.
Description of Benefits
• Children under age 26. Coverage will be continued until the end of the month in which the child becomes age 26. • Children placed with you or your covered spouse for adoption or whom you or your covered spouse have legally adopted. • Children for whom you or your covered spouse have been appointed legal guardian by court order. • Grandchildren of yours or your covered spouse if: • The parent of the grandchild is unmarried. • The parent of the grandchild is a covered eligible dependent.
In-Network
or out-of-network with an authorized referral
Amounts are a % of the allowed charge after the deductible is met.
Who is eligible for benefits? If you have family coverage, benefits are available for you, your spouse and eligible children. If you have single plus dependent coverage, you and your eligible children are covered. Eligible children include:
Copayment Amount you pay per visit
Inpatient Hospital Services Outpatient Hospital Services
Out-of-Network
Amounts are a % of the allowed charge after the deductible is met.
Before out-of-pocket After out-of-pocket Before out-of-pocket After out-of-pocket maximum is met maximum is met maximum is met maximum is met 90%
100%
80%
100%
90%
100%
80%
100%
• Children incapable of self-support because of an intellectual disability or a physical handicap that began before they reached 26 years of age and who are primarily dependent on you or your covered spouse.
Outpatient prescription drug benefits. This benefit plan includes a preferred pharmacy network. When you use this national network, your claims are filed for you. Participating pharmacists also use a computer database to: • Check for possible interactions between prescriptions. • Find any drug duplications. • Identify overuse or underuse of your medication.
$20
80%
100%
80%
100%
Benefits are based on the medical guidelines established by Blue Cross Blue Shield of North Dakota. Deductible does not apply in-network.
Occupational & Speech Therapy
$20
80%
100%
80%
100%
Benefits are available for 90 consecutive calendar days per condition beginning on the date of the 1st therapy treatment for the condition. Additional benefits may be allowed after the 90 days when medically appropriate and necessary. Deductible does not apply in-network.
90%
100%
80%
100%
Professional Health Care Provider Services Inpatient, Outpatient & Surgical Services
Wellness Services Well Child Care (to member’s 6th birthday)
$25
100%
100%
no coverage
no coverage
Deductible does not apply.
Preventive Screening Services (members 6 and older)
$25
100%
100%
no coverage
no coverage
Maximum benefit allowance of $200 per member per benefit period. Benefits beyond the maximum benefit allowance will be subject to cost sharing amounts. Deductible does not apply.
Immunizations
100%
100%
100%
100%
Deductible does not apply.
Mammography, Pap Smear, Fecal Occult Blood Testing & Prostate Cancer Screening Services
100%
100%
80%
100%
The number of visits for these services may vary by age group. Refer to the benefit plan for details. Deductible does not apply to these services in-network.
90%
100%
80%
100%
Deductible does not apply in-network.
Lab, X-ray, MRI
90%
100%
80%
100%
Allergy Testing
80%
100%
80%
100%
90%
100%
80%
100%
90%
100%
80%
100%
Deductible does not apply for pre and postnatal care.
100% / 90%
100%
100% / 80%
100%
Preauthorization may be required. Refer to the benefit plan for details.
Home & Office Visits Diagnostic Services
$25
Radiation Therapy, Chemotherapy & Dialysis Maternity Services Inpatient, Outpatient, Pre & Postnatal Care
Psychiatric & Substance Abuse Services Inpatient, Partial Hospitalization, Intensive Outpatient Program, Residential Treatment & Outpatient Services
• Determine if a generic equivalent is available for your prescription drug and if the medication appears on a list of quality and cost-effective drugs. Drugs on this list, called formulary drugs, are covered at the maximum benefit amount.
Emergency Services
Prescription drugs are categorized as formulary, nonformulary, nonpayable or restricted-use drugs. A restricted-use drug may have a dispensing limit and/or require prior approval.
Urgent Care Services
Benefits are available nationwide at any pharmacy participating in the preferred pharmacy network. To locate a participating pharmacy, call the special toll-free number listed on the back of your ID card.
Ambulance Services Skilled Nursing Facility Services Home Health Care Services Hospice Services Chiropractic Services
When a generic drug is available but not accepted, the member is responsible for the difference between the cost of the generic and brand name drug. Prescriptions filled at a nonparticipating pharmacy must be paid in full and a paper claim submitted. All costs above the allowance are the member’s responsibility.
Preauthorization may be required.
Physical Therapy
• The parent is primarily dependent on you for their support. • Children for whom you or your covered spouse are required by court order to provide health benefits.
Special Conditions
with a participating BCBSND provider
90%
100%
90%
100%
Preauthorization is not required. In-network deductible applies.
Professional Health Care Provider Visit
$25
90%
100%
90%
100%
Deductible does not apply to the office or emergency room visit.
Emergency Room Charge
$75
90%
100%
90%
100%
Deductible does not apply.
90%
100%
80%
100%
Urgent care services received out-of-network will be reimbursed at the out-of-network level, except when the member is outside the geographic area of their affiliated network. Refer to the benefit plan for details.
Professional Health Care Provider Visit
$25
90%
100%
80%
100%
Emergency Room Charge
$75
90%
100%
80%
100%
80%
100%
80%
100%
In-network deductible applies.
80%
100%
80%
100%
Preauthorization is required.
80%
100%
80%
100%
Preauthorization is required.
80%
100%
80%
100%
Preauthorization is required. In-network deductible applies.
Home & Office Visits
$25
90%
100%
80%
100%
Deductible does not apply when seeing a BCBSND participating chiropractor.
Therapy & Manipulations
$20
80%
100%
80%
100%
Deductible does not apply when seeing a BCBSND participating chiropractor.
90%
100%
80%
100%
80%
100%
80%
100%
Diagnostic Services
Medical Supplies & Equipment Tobacco Cessation Services Related Office Visit
Description of Benefits
Prescription and payable over-the-counter tobacco cessation medications or drugs obtained with a prescription order are paid under the Outpatient Prescription Medications or Drugs benefit below. Refer to the benefit plan for details. $25
90%
100%
Copayment
80%
100%
Benefit Amount
Deductible does not apply in-network.
Special Conditions
Before prescription drug coinsurance maximum is met
After prescription drug coinsurance maximum is met
Outpatient Prescription Medications or Drugs Retail Pharmacy Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Formulary drugs
$15
80%
100%
Nonformulary drugs
$15
50% sanction
50% sanction
Preferred Mail Order Pharmacy
Preferred Specialty Pharmacy This benefit grid presents a brief overview of covered services and payment levels of this product. It should not be used to determine whether your health care expenses will be paid. The written benefit plan governs the benefits available.
One copayment amount per prescription order or refill for a 34-day supply. Two copayment amounts per prescription order or refill for a 35-60 day supply. Three copayment amounts per prescription order or refill for a 61-100 day supply. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply. Two copayment amounts per prescription order or refill for a 61-100 day supply. Mail order prescriptions must be received from the preferred mail order pharmacy. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply. One copayment amount per prescription order or refill for a 34-day supply. Two copayment amount per prescription order or refill for a 35-100 day supply. Specialty Drugs must be received from the preferred specialty pharmacy network. Benefits are subject to the Outpatient Prescription Drug Coinsurance Maximum Amount. Deductible does not apply.
Plan 250 Cost Sharing Amounts In-Network
Out-of-Network
Single Participation
Or an individual family member $250
$500
Coinsurance maximum
$1,000
$2,000
Out-of-pocket maximum
$1,250
$2,500
Deductible amount
SelectChoice An overview of benefits and services provided by this plan.
Single Plus Dependent Participation Individual plus eligible children
$375
$750
Coinsurance maximum
$1,500
$3,000
Out-of-pocket maximum
$1,875
$3,750
Deductible amount
Family Participation $500
$1,000
Coinsurance maximum
$2,000
$4,000
Out-of-pocket maximum
$2,500
$5,000
Deductible amount
This chart reflects the cost sharing amounts for each benefit period. In-network and out-of-network amounts accumulate jointly. Outpatient prescription drug cost sharing amounts do not apply to the out-of-pocket maximum.
Outpatient Prescription Drug Coinsurance Maximum Amount
$1,000 per member per benefit period
When the prescription drug coinsurance maximum amount has been met, copayment amounts will continue to apply, and formulary drugs will be covered at 100% of the allowed charge for the remainder of the benefit period. Copayment amounts and the nonformulary sanction do not apply to this coinsurance maximum.
Annual Enrollment Period If an eligible employee or eligible dependent does not apply when first eligible, they may apply during the annual enrollment period. See the benefit plan for special enrollment provisions.
This grid describes what the Plan Administrator believes to be a “grandfathered health plan” under the Patient Protection and Affordable Care Act (Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Subscriber’s Benefit Plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any Cost Sharing Amounts. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to BCBSND at the telephone number and address on the back of the Member’s Identification Card. If this Benefit Plan is affected by ERISA, the Member may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. Members may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.
This health plan is that of your employer. Blue Cross Blue Shield of North Dakota is serving only as the Claims Administrator and does not assume any financial risk except for stop-loss coverage.
Call toll-free 1-800-247-3876 www.BCBSND.com
For premium rates and further details of the coverage, including definitions; exclusions; criteria for medically appropriate and necessary care; credentialing process; confidentiality policy; description of experimental drugs, medical devices or treatments; grievance and appeals process; provider listings; drugs eligible for coverage; reductions or limitations; and the terms under which this benefit plan may be continued, see your Account Executive or write to Blue Cross Blue Shield of North Dakota. RW18
Effective 1-1-2018
29378128 9-17
This is a grandfathered Benefit Plan under the Patient Protection and Affordable Care Act (PPACA).
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the following disclosure: Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: - 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, please call Member Services at 1-800-342-4718 (toll-free) or through the North Dakota Relay at 1-800-366-6888 or 711. If you believe that Blue Cross Blue Shield of North Dakota 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 4510 13th Ave S Fargo, ND 58121 701-297-1638 or North Dakota Relay at 800-366-6888 or 711 701-282-1804 (fax)
[email protected] (email) You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 800-342-4718. 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, DC 20201 800-368-1019 or 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-342-4718 (TTY: 1-800-366-6888 o 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-342-4718 (TTY: 1-800-366-6888 oder 711). 4510 13th Avenue South, Fargo, North Dakota 58121 Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association 29376608
11-16 Noridian Mutual Insurance Company
繁體中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-342-4718（TTY：1-800-366-6888 或 711）。 Oroomiffa (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-342-4718 (TTY: 1-800-366-6888 ykn 711). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-342-4718 (TTY: 1-800-366-6888 hoặc 711). Ikirundi (Bantu – Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800-342-4718 (TTY: 1-800-366-6888 canke 711). ( العربيةArabic) : (رقم هاتف الصم والبكم800-342-4718-1 اتصل برقم. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان، إذا كنت تتحدث اذكر اللغة:ملحوظة .) 711 أو1-800-366-6888 Kiswahili (Swahili) KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 1-800-342-4718 (TTY: 1-800-366-6888 au 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-342-4718 (телетайп: 1-800-366-6888 или 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-342-4718 （TTY: 1-800-366-6888 または 711）まで、お電話にてご連絡ください。 नेपाली (Nepali)
ध्यान दिनुहोस ्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको ननम्तत भाषा सहायता सेवाहरू ननिःशुल्क रूपमा उपलब्ध छ । फोन गनुहोस ् 1-800-342-4718 (दिदिवार्इ: 1-800-366-6888 वा 711) ।
Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-342-4718 (ATS : 1-800-366-6888 ou 711). 한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-342-4718 (TTY: 1-800-366-6888 또는 711)번으로 전화해 주십시오. Tagalog (Tagalog – Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-342-4718 (TTY: 1-800-366-6888 o 711). Norsk (Norwegian) MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-800-342-4718 (TTY: 1-800-366-6888 eller 711). Diné Bizaad (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dę́ę́’, t’áá jiik’eh, éí ná hólǫ́, kojį’ hódíílnih 1-800-342-4718 (TTY: 1-800-366-6888 éí doodagó 711.)
