Express Scripts Mail Home Delivery Order Form, Premera Blue Cross Discrimination Sheet (Page 3 of 4) in pdf

Discrimination is Against the Law

Oromoo (Cushite):

Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa

yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee

Premera Blue Cross complies with applicable Federal civil rights laws and

odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa

does not discriminate on the basis of race, color, national origin, age,

ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf

disability, or sex. Premera does not exclude people or treat them differently

yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan

because of race, color, national origin, age, disability or sex.

jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin

odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.

Premera:

Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.

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

effectively with us, such as:

Français (French):

• Qualified sign language interpreters

Cet avis a d'importantes informations. Cet avis peut avoir d'importantes

• Written information in other formats (large print, audio, accessible

informations sur votre demande ou la couverture par l'intermédiaire de

electronic formats, other formats)

Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous

• Provides free language services to people whose primary language is not

devrez peut-être prendre des mesures par certains délais pour maintenir

English, such as:

votre couverture de santé ou d'aide avec les coûts. Vous avez le droit

• Qualified interpreters

d'obtenir cette information et de l’aide dans votre langue à aucun coût.

• Information written in other languages

Appelez le 800-722-1471 (TTY: 800-842-5357).

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

Kreyòl ayisyen (Creole):

Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen

If you believe that Premera has failed to provide these services or

enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti

discriminated in another way on the basis of race, color, national origin, age,

asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan

disability, or sex, you can file a grievance with:

avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka

Civil Rights Coordinator - Complaints and Appeals

kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo.

PO Box 91102, Seattle, WA 98111

Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,

Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357

san ou pa gen pou peye pou sa. Rele nan 800-722-1471

(TTY: 800-842-5357).

You can file a grievance in person or by mail, fax, or email. If you need help

Deutsche (German):

filing a grievance, the Civil Rights Coordinator is available to help you.

Diese Benachrichtigung enthält wichtige Informationen. Diese

Benachrichtigung enthält unter Umständen wichtige Informationen

You can also file a civil rights complaint with the U.S. Department of Health

bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera

and Human Services, Office for Civil Rights, electronically through the

Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser

Office for Civil Rights Complaint Portal, available at

Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten

U.S. Department of Health and Human Services

zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in

200 Independence Avenue SW, Room 509F, HHH Building

Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471

Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD)

(TTY: 800-842-5357).

Complaint forms are available at

Hmoob (Hmong):

Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum

Getting Help in Other Languages

tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv

thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue

This Notice has Important Information. This notice may have important

Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv

information about your application or coverage through Premera Blue

no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub

Cross. There may be key dates in this notice. You may need to take action

dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj

by certain deadlines to keep your health coverage or help with costs. You

yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob

have the right to get this information and help in your language at no cost.

ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau

Call 800-722-1471 (TTY: 800-842-5357).

ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471

(TTY: 800-842-5357).

አማሪኛ (Amharic):

ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue

Iloko (Ilocano):

Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ።

Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a

የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ

pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion

ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት

maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue

አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።

Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar.

Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti

‫العربية‬

(Arabic):

partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti

‫أو‬

‫طلبك‬

‫بخصوص‬

‫مھمة‬

‫معلومات‬

‫اإلشعار‬

‫ھذا‬

‫قد يحوي‬

‫ھامة‬

‫معلومات‬

‫اإلشعار‬

‫ھذا‬

‫يحوي‬

salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti

‫مھمة‬

‫قد تكون ھناك تواريخ‬

Premera Blue Cross

‫خالل‬

‫من‬

‫التغطية التي تريد الحصول عليھا‬

daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti

‫للمساعدة‬

‫أو‬

‫الصحية‬

‫تغطيتك‬

‫على‬

‫للحفاظ‬

‫معينة‬

‫تواريخ‬

‫في‬

‫إجراء‬

‫التخاذ‬

‫تحتاج‬

‫اإلشعار. وقد‬

‫ھذا‬

‫في‬

bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).

‫اتصل‬

‫تكلفة‬

‫أية‬

‫دون تكبد‬

‫بلغتك‬

‫والمساعدة‬

‫ھذه المعلومات‬

‫على‬

‫يحق لك الحصول‬

.‫التكاليف‬

‫دفع‬

‫في‬

‫بـ‬

800-722-1471 (TTY: 800-842-5357)

Italiano (Italian):

Questo avviso contiene informazioni importanti. Questo avviso può contenere

informazioni importanti sulla tua domanda o copertura attraverso Premera

中文 (Chinese):

Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe

本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的

essere necessario un tuo intervento entro una scadenza determinata per

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

consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di

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

ottenere queste informazioni e assistenza nella tua lingua gratuitamente.

語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。

Chiama 800-722-1471 (TTY: 800-842-5357).

037338 (07-2016)

Express Scripts Mail Home Delivery Order Form, Premera Blue Cross Discrimination Sheet Page 3

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