EXPRESS SCRIPTS* Notice of Adverse Benefit Determination Date of Notice: 09/07/2017 Name of Plan: VERIZON COMMUNICATIONS TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800.753.2851 CHINESE (8K) NOSRABEECh ene, JARETE E55 800.753.2851. NAVAJO (Dine): Dinek'ehgo shika atohwol ninisingo, kwiijigo hoine’ 800.753.2851, {nis document contains important information that you should retain for your records. This document serves as notice of an adverse. beneht aa ermination, We have declined on behalf of your plan to provide benefits, in whole or im Part, for Butrans 10 meg/hr PATCH TOWK. if You think this determination was mage in error, you nave the Tight to appgai. (See additional ag28 for information about your appeal rights.) ee eee —, Gase Details: Patient Nai i 1D Number: wee eee Address: feet i ¢ 8 (¢ asec ‘Date of Service: 09/05/2017 05 51pm (Case (claim) #: | te of ‘Reason for Denial (in whole or in part * {verade is provided in situations where the patient has tried atleast one preferred ER eicaltemative: FENTANYLHYDROMORPHONE ER, MORPHINE SULFATE ER, OXYMORPHONE HCL ER,HYSINGLA ER,NUCYNTA ER, Coverage cannot be authorized at this tir Amt flowed Other ‘olnsurance (ther Am Ami Pal Charged Amt. insurance | [Not Covered | / | AWA WA WA Wa waa NA Compa ans Seb Noting Company. ARehs Resse. Express Sits ana“ ogo are trademarks of Exsras Sep Heaing Sompar endo: f secures, Al ahercemana rete pope ie eae EMEAO726 LT472s66 cHST HSE10 Credit toward Deductible; N/A Description of service: ea Drug coverage Sincerely, Coverage Review Department Express Scripts