Medical Exception/ Prior Authorization/Precertification* Request for Prescription Medications

Fax this form to: 1-877-269-9916 OR

Submit your request online at: https://navinet.navimedix.com/Main.asp Visit www.aetna.com/formulary to access

our Pharmacy Clinical Policy Bulletins.

For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time

Patient Information Prescriber Information

Patient Name Today’s Date

Patient Insurance ID Number Physician Name

Patient Address, City, State, ZIP Physician Address

Home Telephone M.D. Office Telephone Number

Gender

Male Female

Patient Date of Birth M.D. Office Fax Number

Diagnosis and Medical Information

Medication Strength Frequency

Expected Length of Therapy Quantity Day Supply If this is a continuation of therapy, how long has the patient been on the medication?

PLEASE CHECK ALL BOXES THAT APPLY:

Do you want a drug specific prior authorization criteria form faxed to your office? Yes No (If yes, no further questions are required).

What condition is the drug being prescribed for? ICD code

Diagnosis

Does the patient have a diagnosis of cancer? Yes No

Please list all medications the patient has tried specific to the diagnosis and specify below:

Therapeutic failure, including length of therapy for each drug:

Drugs (s) contraindicated:

Adverse even (e.g., toxicity, allergy) for each drug:

Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? If so, specify anticipated significant adverse event:

Has the condition been confirmed by diagnostic testing? If so, please provide diagnostic test and date:

Does the patient have a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature? If so, please provide documentation:

Does the patient require a specific dosage form (e.g., suspension, solution, injection)? If so, please provide dosage form:

Are additional risk factors (e.g., GI risk, cardiovascular risk, age) present? If so, please provide risk factors:

Other: Please provide additional relevant information:

REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION.

PLEASE COMPLETE CORRESPONDING SECTION ON BACK PAGE FOR THE SPECIFIC DRUG/CLASS LISTED BELOW.

Antifungals/Antiemetic (5-HT3) Agents/Celebrex/Erectile Dysfunction Agents/Proton Pump Inhibitors/Protopic

Provigil/Nuvigil/Stimulants/Tazorac/Tretinoin Products/Triptans

**FOR ANY DRUG/CLASS NOT L ISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES**

PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS

I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is available for review if requested by the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government or any state government may be subject to civil penalties and treble damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733.

Prescriber Signature Date

Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents.

CB-21 (8-16) Page 1 of 7

PLEASE COMPLETE CORRESPONDING SECTION FOR THESE SPECIFIC DRUGS/CLASSES LISTED BELOW AND CIRCLE THE APPROPRIATE ANSWER OR SUPPLY RESPONSE.

ANTIFUNGALS: LAMISIL, SPORANOX, PENLAC, DIFLUCAN

Does the patient have secondary medical risk factors? Please specify which risk factor(s):

If the patient has a diagnosis of Onychomycosis, does the infection involve the toenails, fingernails or both? Please circle

If the diagnosis is Tinea corporis or Tinea cruris, does the patient require systemic therapy or have more extensive superficial infections? Yes No

ANTIEMETIC (5-HT3) AGENTS: (Ondansetron quantities of 12 or less per 30 days do not require a prior authorization)

Is the patient receiving moderate to highly emetogenic chemotherapy? Monthly frequency Yes No

Is the patient receiving radiation therapy? Monthly frequency Yes No

If the patient has a diagnosis of Hyperemesis Gravidarum, has the patient experienced an inadequate treatment response to t wo of the following medications?

vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan) or metoclopramide (Reglan)? Yes No

CELEBREX:

Is the patient at risk for a severe NSAID-related gastrointestinal (GI) adverse event (e.g., NSAID associated gastric ulcer, GI bleed)? Yes No

ERECTILE DYSFUNCTION: CIALIS, LEVITRA, VIAGRA, ALPROSTADIL

Does the patient require nitrate therapy on a regular OR on an intermittent basis, or is the patient currently taking another ED medication? Yes No

If a diagnosis of erectile dysfunction, is it due to neurogenic etiology, vasculogenic etiology, psychogenic etiology or mixed etiology? Please circle.

Is it being used for symptomatic Benign Prostatic Hyperplasia (BPH)? Yes No

PROTON PUMP INHIBITORS:

Does the patient have frequent and severe symptoms of GERD (e.g., heartburn, regurgitation)? Yes No

Does the patient have atypical symptoms or complications of GERD (e.g., dysphagia, hoarseness, erosive esophagitis)? Yes No

PROTOPIC:

Has the patient had a therapeutic failure of a topical corticosteroid? Yes No

PROVIGIL/NUVIGIL:

If the patient has a diagnosis of Obstructive Sleep Apnea, is the patient currently using a continuous positive airway pressure (CPAP) machine or other device? Yes No

STIMULANTS: AMPHETAMINES, METHYLPHENIDATES, STRATTERA

Is this a renewal of therapy? Yes No

TAZORAC/ TRETINOIN PRODUCTS:

Has the patient tried and failed products from the following categories: Salicylic Acid Products OR Benzoyl Peroxide products? Yes No

TRIPTANS:

Is the patient currently using migraine prophylactic therapy (e.g., amitriptyline, propranolol, timolol)? Yes No

CB-21 (8-16) Page 2 of 7

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group

of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and

their affiliates (Aetna).

CB-21 (8-16) Page 3 of 7

TIY:711

This Notice has Important Information. You may need to take action by certain dates to keep your health coverage or help with costs. For help in English at no cost, you can call the number on your ID

card. (English)

Este aviso contiene informaci6n importante. Es posible que deba realizar determinadas acciones en

ciertas fechas para mantener su cobertura de salud u obtener ayuda para pagar las costos. Para obtener

ayuda en espanol sin cargo alguno, llame al numero que figura en su tarjeta de identificaci6n. (Spanish)

*~~fil·-~•mD~~-~~aM~B~MS~fi~. m~~~~--~~~~M~m~m W:lo Y.a~~~lf~f~i:ti:>c¥W:J. 1~~t~'HT1~1*~-FJ:.~~~i!i%mfl o (Chinese)

Le present avis contient des informations importantes. Vous devrez peut-etre prendre des mesures a partir de certaines dates pour garder votre couverture sante ou obtenir des aides pour payer les couts.

Pour obtenir de l'a ide en Fra n~a is sans fra is, vous pouvez a ppeler le numero su r votre ca rte

d'identification. (French)

Ang Abisong ito ay Naglalaman ng Mahalagang lmpormasyon. Maaaring kailanganin mong gumawa ng

aksyon sa tiyak na mga petsa upang mapanatili ang pagsakop sa iyong kalusugan o tulong na may gastos.

Para sa tulong sa Tagalog na walang gastos, maaari kang tumawag sa numero sa iyong ID card. (Tagalog)

Dii saad iliinii baa hane'. Dii nike'esti'igii ei daadago beesa da bee nikci a 'daawaligii bikcia'ga da at'ee daaleel aka t' aadaa bee e' e' aahi baa yilkaahg66 tsxWga has ht' e diiliil nii da daaleeL (Dine k' ehji) bee shika a'daowol ninizingo Naaltsoos nanitingo bee neeho'dolzinigii beesh bee hane'i bikaa' aka aaji' hadiilnih t'aadao b~~h ilinig66 (Navajo)

Diese Mitteilung enthalt wichtige lnformationen. Wenn Sie lhren Krankenversicherungsschutz

beibehalten mochten oder Hilfe beim Bestreiten der Kosten benotigen, mussen Sie u. U. innerhalb einer

bestimmten Frist handeln. Fur kostenfreie Hilfe auf Deutsch konnen Sie die Nummer auf lhrer

Versicherungskarte anrufen. (German)

.ev attfl:MJ+Y m:J-1. ool:4' M(J)<:: \>ms 'liit-19'7 f\ovmn<P ro~<fl nhff:Y n-rroo'r <P<;t- ID'O'I' ro,e. 1'"1rtc ov"lrtr M1lsPr:: m~ !l:;Jff: t'\"'1"17r(h"'!Cn nov;tf,P\>rosP ([(\ID' r'lt:\h ov,e.rot:\ ~fl\l\-:: (Amharic)

Ji ~I~~ J:.lb..ll o.l~I *ly.ll ~ :i....j)\ll wl.,IY.>-'?I :i.:..:;:; oi ~ l:il .4 wl.._,l...... ~ J .... .t'?I 11\ '-f.ih -~*' :i.!~ ~ .l_,?.y.ll ~)\ ~ J-,..oJ')I ~ J.J1+o (~yJI :wll) ~o.icWI ~J .~l.5.:ill ~ o.icl.ui.. ~ J~

(Arabic)

~l° ~~ S~'[Gf' ~~~I ~~ ~ ~ ~'3~~ ~ ~ \S1Gfl ~ ~

m >ITT"101rn 01Gfl ~ ~ 61Cf:fl ~ ~'f m ~ ™' M<>i1~'11 <n~"'1"T ~Pfl""M 51~131~1~ \S1Gfl ~~ ~™ ~ m 01" ~ ~ ~IM ~ ~ m ~I (Bengali­

Bangala)

Beeksisni kun odeefannoo barbachisa of keessa qaba. Fayummaa keessaan egachuuf ykn wa'ee

fayyumaa keessanii ilaalchisee gargarfa argachuufii yeroo merta'ee kana keessatti tarkanfii fudhachu

qabdu. Afaan (oromoon) basii tokko malee lakkofsa enyumessaa keessanin bililuu dandessuu. (Cushite)

CB-21 (8-16) Page 4 of 7

Dit bericht bevat belangrijke informatie. Het kan zijn dat u v66r bepaalde data actie moet ondernemen

om uw zorgverzekering of bijstand in de kosten te behouden. Voor gratis hulp in het Nederlands kunt u

het nummer op uw identiteitskaart bellen. (Dutch)

Avi sa a gen enfomasyon enpotan ladan. Petet yap egzije ou pou pran seten aksyon nan seten dat limit

yo pou kenbe pwoteksyon sante ou yo oswa ede avek depans yo. Pou jwenn asistans gratis nan lang

Kreyol Ayisyen, ou kapab rele nimewo a yo ekri nan kat idantifikasyon ou. (French Creole)

H napouaa avaKoivwari REPLEXEL ariµavtLKE<; nAripo<l>opiE<;. 'lowc; xpnam£( va npo~dT£ 0£ Kano Lee;

£v£pynec; µfoa 0£ ouyKeKpLµEvec; npo8wµ(ec; yLa va 0Lmrip~on£ TllV uynovoµLK~ KaA.ul!Jri ~ ~o~8na

oac; µ£ xp£wori. rm ~o~8na ma £AAllVLKa xwp(c; xp£wori, µnope fr£ va KaAEon£ rnv apL8µ6 nou

avaypa<l>nm oTriv Kapm oac;. (Greek)

:a.t.L .-t.LfZ~+tL ;b.\,~ ll~,q.-t.1 +tLfurl.1 0. rl.lll~ :a.t.:1~ &i1t.t ~t.t.1+tL ·>1J11.1.L ~N1 LLlil. rl.lll::/..L :a.t.L:liJl.I. LcL+tH1 Lfl(C-m1.-t.1 ::/..~ll

aj_c.{(ti.<{ !JAL 1 "J.l!JAL ~::i_c{l LL~il :a.t.~ql "l>t~ «tLJLqql, LL~il. (~66'::/..Lrl.1)+tl hl() LL~L "l>t~ LcHL llSS il.Cflqql lll~ rl.lll::/..L

:a.t.LCfl"l>t LL:tlll :a.t.L~Ell .-i.C>t::i.. LL::/..~<{ ~a ~Lhl t9l. (Gujarati)

~ ~ ~ "1101411fl ~I ~ .wrafi ~<r 'CfiClt;r CFi1' ~ ~ m ~

't'i~Flfr1 I ~

* ~ ~ ~ ~ c=tCfi 411~a I~ CR'ofr ~ ~ ~I ~ ~ (>l'l7l"(1 ~

(~) 't'l~Flfrtl ~ ~' J1lq" ~ ~ qi@ G""{ ~ ~ G""{ ~ Cfi1" ~

~l(Hindi)

* *

Daim ntawv ceeb toom no muaj lus qhia tseem ceeb. Ko j yuav ts um tau ua qee yam ua ntej cov sib

hawm teev tseg kom koj txoj kev pab kho mob dawb las yog kev pab kho mob them nqi qis muaj txuas

mus ntxiv. Yog xav tau kev pab ha is koj horn lus (Hmoob) pub dawb, koj hu tau rau tus xov tooj ntawm

koj daim npav. (Hmong)

Qkwa a nwere Ozi di Mkpa. ! nwere ike chQQ ime mmee n't,1f9d1,1 deeti iji dozie mkpuchi ah1,1ike gi

ma9b1,1 nye aka na imefu ego. Maka enyemaka n'lgbo nke efughi ego, i nwere ike kpQQ n9mba nQ na

kaadi ID gj. (Ibo)

Questa avviso contiene importanti informazioni. Potrebbe essere necessario intraprendere un'azione

entro alcune date particolare per conservare la copertura o l'assistenza sanitaria entro i costi previsti.

Per ricevere assistenza in (italiano) gratuitamente, puo chiamare ii numero di telefono riportato sulla

Sua scheda identificativa. (Italian)

*il~lct;t-11.Jfl1.>~ i;tt-c:"t o i.lfflH~Bi~1*t~9 .Q f.::61), t L < l;i:Jl:Jtl ~t(j]~ .Q f.::61) 1=-JE:Wl B *'"( i=t~ll: ~~ L.id: rtnlitd: i; t~ (, \~.g.f,){&> ~) *9 0 1lttf4!= -c B *~R'"(Sri:l~(, \.g.ptt!=id: ~) f.::(,\~.g.l;i:ID:t.J- f-:'!=~C.jl~;h,-C(,\.Qfi=~*'"(d-.)~~i!i< t.=~(,\ o (Japanese)

001:S:~l~w3Sp~:001c;ii001o%iro~3;>~3~~tm'.XfX='u3:01~"'1J'.D1~l9~1 ~-,ro5001v:io~[XD~~~rostmo~un:3:tm1 £[X9,?£

pQ~m1"1c©~oo1:i:rr&w?oo?1~m1CJ?~c©~ro5~001ro~'JJi'fXDS0qi1.oo<.0~~~rostm"'~~oo1o'>n%:0>51.<j>w(m~~)~rosoo£p3:oo1ro

50'JJi'fXD~~n:n~J~trfi:o3o'>~~[X'i1ro5'.Di3fXDS'l'~~ ~;;i:cr,>'.Dc8qpo3~~ (Karen)

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tg; ~ ~ 0 Al121 ~ gj ID 3~ c: OJI 4"~§ 12:12.~ ~!:2loH "?-GJ Al 2.. (Korean)

CB-21 (8-16) Page 5 of 7

Ce~-qt ma kE f>eqe b~ kpa qE qo 66 rh bU. M kS 6£ rh ke clE elf£ oe nyu hwf: 6£ we oe wa mu ny£n£ ctaun cee-ctf:f: muEE ke zi. M: dyiE naa nyufn, nif, wa mu ni w£ je gbo gni>un mJJ wa mu ni je p£in J ju ke rh dyi WE nf. M ()£in gbo-kpa-kpa dyeE Bas:S?>-wuctu mu DE rh ke se wfclf eta p£f:. f)a n?>oa nia ni ID­KaaJ l6E. (Kru-Bassa)

J.! Jlfa •• )-:1.i ~f'S..J..J, ·' .-'!! .-'!! .-'!! .-'!! .-'!!

'I.I fa. ~l.SoJ~ ~l.J# ~ ~ wK.t ~~ ~...i .~..J. '-d~lj r.,;..J.l.i 4..l.l..l~I ...i r.l,j

~ljl>.i ~\.... "' "' '<..S.lJfi. j 4-: c..s:!l-..!Y.4-: c..s:!~~ ,_;tJ ..J. Jo J J.! .~ )-:_ ,_;IJ ..J. Jo J 0\: ~ JJW r.,;~ ~~ JS.4-: 'I.I ·' UJ~ljo.l fa. (Kurdish)w_? ~~ _;JJS. JU~~ oJL.j 4-: ~ r.,;.l.lo~

cc~'.)n1u:;:,:;uuDD~J.Ju~1~u. ' ~

ui1ue1o~:;ne'.)tJ:;nuoC11J.J w1v~uouffi§J.Jelou cwesn:;:,1n1ulJ:;nu~J.Jel8'.):;:,2:;w1u ID ~OVnU~'1V~'1V. tj'1ui1une'.)n1uelo1~~ovcfil,enuw1;1~10 iov0c:;:,ve)1, ui1u:;:,1J.J1oiUlm1crJJ1vc~n ffi~~uuou:;~160 2e'.) ui1u. (Laotian)

truGCT~ 2 ~ lliltlrn ~ tf12 rifitfl 2 fi5212 j '1 tiiiffiGU:J1tgruii~mri t~hHnrutfaggmrumfi t~Hj9 ~rum 2 filjntJitlUUGllill liJt~ii fll2m rl y ~ ~liJ fUltflUGllill liJITTITT '1 fUltflU~ ~mm mMim

.._. 1wirnnfl~fliu

cvq Hiirnumfigtl1ru2mruriiwrutflmmuumflrutflru22mri5Hii'1

LI d Fl ~ q-

(Mon-Khmer, Cambodian)

<IT (il0'11Cl"ll 11"1~<-<"cl'!~ "1I0'1ct11{'1 ~ 1 ('1q1~<>1 %$'l~Cfl~ ~~<r ~ %$'l~0'1 err ('1q1~ct1~ ~ 3j,Cfcilcr1~Cl"ll

'fl~ I <I ('11 tTT3if ~ m:r<r-~ Cf;Td1'-Cfl l'lCI 181 ~ ~ 0'1 'fl Cfe I ~ Cl"IT fat: ~rc;:q:; m"IT 'fl~ I <I ('11 ~ ~ ~

q130'1Cfll c;r@t ('1q l~Cfl~ ~-q-:;[Cl"IT ~ dl'RQCfl~ 0'1""'iHCl"I I tfITaPlaj,~~'fl, I (Nepali)

Lek ke an;,gic thonrilic br ha pig apfath. Yen abr ha ye ke lekke y1n ne doc loi te c1n gaau kua ne thaa

bre yen ha loi, ago aguiEr duon bi:n ya b te no!J Ak1m kua kony ne yoony de wal ke pan Akim IJOOt ke to

thi:n abac ke ci:n weu borke. Yen na br bi: yi: kony ne g££r de thokic abac ke ci:n weu brke, ke yi: col nomba fo ne ID card duic. (Nilotic-Dinka)

Selle Notice hot wichtige Information. Vielleicht brauchscht du eppes duhe bis en gewisse Daadem um dei Gsund Inschurans zu behalde odder mit Koschde zu helf e. Fer Helfe in Deitsch mit kenne Koschde, du kannscht die Nummer uff dei ID Kaarde aarufe. (Pennsylvanian Dutch)

~1....J.i r.,;1...l. ~j.i. a..:...s:.....s: y J .i~ W..)I... ~.1:..i:... r.,;IJ!W .iJilt rS'l .1.5. w..ol ~ .w..ol ~~)I.bl r.,;J'•.::.. ¥-)I.bl U;!I

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(Farsi).~ J...,t.::.. U"W .i~ c..s:!l.uiW w).S: <..SJJ

Niniejsze pismo zawiera waine informacje. Aby zachowac ubezpieczenie zdrowotne lub zaoszczydzic pieniqdze konieczne moze bye podjycie pewnych dzialaii w okre§lonych terminach. Aby uzyskac bezplatnie pomoc w jyzyku polskim, proszy zadzwonic pod numer podany na karcie identyfikacyjnej. (Polish)

CB-21 (8-16) Page 6 of 7

Este Aviso disponibiliza lnforma!;:aO lmportante. Podera ter de tomar determinadas ac;:oes ate certas

datas para manter a cobertura do seu seguro de saude ou auxflio com custos e despesas. Podera

contactar o numero disponfvel no seu cartao de identificac;:ao para obter assistencia em portugues

gratuita mente. (Portuguese)

B 3TOM YBeAOMJleHHH COAep>KaTc.R Ba>KHble cBeAeHH.R. ,l1,m1 mro YT06b1 coxpaHlffb CTpaxoBKY 111rn

noJ1yY11Tb noMOW,b B onflaTe noflyYeHHblX ycflyr, BaM, B03MO}f{HO, HY}f{HO '-ITO-To cp,eflaTb B cpoK11,

yKa3aHHble B 3TOM yBeAOMJ1eH1111. EcJ111 BaM HY}f{Ha noMOW,b Ha pyccKoM .fl3b1Ke, Bbl MO}f{eTe ee

6ecnflaTHo noJ1yY11Tb, no3BOHl1B no Tefle<j>oHy, yKa3aHHOMY Ha Bawei111AeHrn<j>11Kau,110HHoi1 KapTO'-IKe

yyacTH11Ka nflaHa. (Russian)

Ova obavijest sadrzi vafoe informacije. Mazda cete morati poduzeti odredene mjere do odredenog

datuma kako biste zadrfali zdravstveno osiguranje iii pomoc za placanje troskova. Za besplatnu pomoc

na hrvatskom jeziku mo:Zete da pozovete broj koji se nalazi na Vasoj identifikacijskoj kartici. (Croatian)

~~:\ r<'.C ~9~ r;.'¥ih.::i ~ ~µ. ~~ ~ . r;.'~r:t' r;.'~<;lli-:lccii · ~·~r;.' r;.'~~ r;.'mr:t'

~ 4- ~~ ~~ ..... ~0" ( ~) r;.'~~<T> r<'.C • rq.~~ r;.'~~q, ~ r;.'~0" ":'\9~~r::6 ~

( Syriac-Assyrian ) • ":'\9~~=" r<'..04 4- ~"

~ $t3!:J~ ~~~~~ ~~~<fo eoa. !b :,,..~ s.jo~ eoruS'.jt:".'!)~ dr:J"' ~ru..J~ ~~®~~tlo §'<SS>,

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e~l ~o~ruS> !Dru 5"'5° ~®.j6:>;y(Telugu)

vii! '1 ~mL ~'1iiii6lle:i:I;! ~ 6f 1\0lfl!

i:oirne:iT~~e:i\1~1L 'll 'lUl1 ';i.fl1t1"lu1u vlvln1viu~L vle:i~\1~11)J~)J~';iu\1~1U6'!'6llfl1'V'l'Vi~e:i~11 )J6lf 'J m vi~m ~e:i\1~1 "li

zj1tJ 6l1vi~u~11)J61f1m vi~mtlu (i11tt11vm) 1~t11~L~t1~1"l6fizj1t1

i:oirnGt1m ';jfl 1l'l';i1ulD''1vimm~611vl"l vi'11'uu'JJ~';iU';i:::~1~16lle:i'1i:oJrn (Thai)

B QhOMY noBi,a;oMJieuui c BIDKJIHBa iu<l>opMaQiH. MmKJIHBO, BaM 6y,a;e rro'Ipi6uo mKHTH ,a;e51Ki. 3axo,a;u

,a;o neBHHX ,a;aT, rn;o6 36eperm Barne Me,a;wrne crpaxyBaHH51 a6o 3MeHIIIHTH Barni BHTpaTH. IIJ;o6

6e3nrraTHO O'IpHMaTH iuqmpMaQiIO yKpai:HCbKOIO MOBOIO, TerrecpouyH.re 3a HOMepOM, BKa3aHHM Ha Barniif.

i,a;eHTHcpiKau;i:Erniif. KapTu;i yqacHHKa rmauy. (Ukrainian)

U""'~ fi yT d 2 .l.l.o LJ:.A CiW c w4-IY.,I y ~_.) ).),>! fi ~:Ufi. ~ ~' ·U# wL.).u. t1' LJ:.A ~~ (..)"' yT 'd 2 c:}~ ~k.. .l.l.o LJ:.A (0Yj _J.l)) 2 a.?-~~ ·cl~ .Jot W_.).JY.::. ~ c:}~ ..)l_j_.)_.)ts i.S..:l u~J.:l

(Urdu).(.)#~~ JlS _.>; _»o..i e:_.).i _.>; 3_.)ts -.;3 _;ii c:}:JI

Thong Bao nay c6 Thong Tin quan tr9ng. Quy vi c6 the can thl!c hi~n vao nhll'ng ngay nhat dinh de gill'

baa hiem cua quy vi ho~c dU'Q'C trQ' giup chi phf. De dU'Q'C trQ' giup b~ng tieng Vi~t mi~n phf, quy vi c6 the

gQi den so di~n thoc;ii ghi tren the ID cua quy vi. (Vietnamese)

lwe Aklyesi yH nl Alaye t6 ~e Pataki nlnu. lwQ le nilo lati gbe lgbes~ ni awQn QjQ kan lati le ~l maa gbadun

aabo fun ltQju Hera ta bf lranlQWQ nfpa sisan ow6 fun ltc'.>ju llera. Fun lranlQWQ ni ede (Yoruba) lal sanw6,

o le pe nQmba t6 wa 16rf kaadl ldanimQ r~. (Yoruba)

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