Vaccination (Immunization)

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1 Policy Number IMM SC Approved By Vaccination (Immunization) UnitedHealthcare Medicare Committee Current Approval Date 04/08/2015 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates. You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies use Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general resource regarding UnitedHealthcare s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare enrollees. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede this policy. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the enrollee s benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations. UnitedHealthcare may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT copyright 2010 (or such other date of publication of CPT) American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Table of Contents Application...2 Summary...2 Overview...2 Reimbursement Guidelines...2 CPT/HCPCS Codes...2 Medicare Covered for Influenza, H1N1, and Pneumococcal...2 Medicare Covered for Hepatitis B...3 Medicare Covered for Tetanus Vaccine...4 Medicare Covered for Rabies Vaccine...4 Medicare Covered for Administration of Tetanus and/or Rabies Vaccines...4 Medicare Non-Covered...5 Medicare Possibly Covered (Part D) Influenza...5 Medicare Possibly Covered (Part D) All Others...6 Questions and Answers...7 References Included (but not limited to):...7 CMS LCD(s)...7 CMS Article(s)...7 CMS Benefit Policy Manual...7 CMS Claims Processing Manual...7 CMS Transmittals...7 Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 1

2 UnitedHealthcare Medicare Advantage Coverage Summaries...8 UnitedHealthcare Reimbursement Policies...8 UnitedHealthcare Medical Policies...8 MLN Matters...8 Others...8 History...8 Application This reimbursement policy applies to services reported using the Health Insurance Claim Form CMS-1500 or its electronic equivalent or its successor form, and services reported using facility claim form CMS-1450 or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians, and other health care professionals. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing UnitedHealthcare. It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid. Compliance with the provisions in this policy is subject to monitoring by pre-payment review and/or post-payment data analysis and subsequent medical review. The effective date of changes/additions/deletions to this policy is the committee meeting date unless otherwise indicated. CPT codes and descriptions are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS restrictions apply to Government use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Current Dental Terminology (CDT), including procedure codes, nomenclature, descriptors, and other data contained therein, is copyright by the American Dental Association, 2002, All rights reserved. CDT is a registered trademark of the American Dental Association. Applicable FARS/DFARS apply. Summary Overview Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment or tetanus antitoxin or booster vaccine. In the absence of injury or direct exposure, preventive immunizations (vaccination or inoculation) against such diseases as smallpox, typhoid and polio, are not covered. In cases where a vaccination or inoculation is excluded from coverage, the entire charge will be denied (such as office visits which are primarily for the purpose of administering a non-covered injection). Reimbursement Guidelines Refer to the CPT/HCPCS Codes tables below for Medicare covered (Part B), Medicare non-covered, and Medicare possibly covered (Part D) immunizations. CPT/HCPCS Codes Medicare Covered for Influenza, H1N1, and Pneumococcal Vaccines listed below are eligible for Medicare Part B payment. These vaccines may be reimbursed regardless of the setting in which they are furnished. In addition, the administration fee for these vaccines is also eligible for payment Influenza virus vaccine, split virus, preservative-free, for intradermal use (for adults age 18-64) Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 2

3 90660 Influenza virus vaccine, live, for intranasal use (for ages 2 yrs 49 yrs - age criteria added effective 05/01/2011) Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for (code effective 11/20/2013) (FDA approved as of 11/20/2013) Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for Pneumococcal conjugate vaccine, 7 valent, for Pneumococcal conjugate vaccine, 13 valent, for Influenza virus vaccine, quadrivalent, live, for intranasal use (effective 01/01/2013) Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for (effective 01/01/2014) Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for (code effective 01/01/2013) Fluzone (Influenza virus vaccine) was approved by the FDA on June 7, Because of this recent FDA approval, CMS is revising the status indicator for CPT code from E (Not paid by Medicare) to L effective June 7, Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for (code effective 01/01/2013) (FDA approved as of 12/14/2012) Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for (code effective 01/01/2013) (FDA approved as of 08/16/2013) Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or Q2033 Influenza vaccine, recombinant hemagglutinin antigens, for (Flublok) (code effective 07/01/2013) (FDA approved 01/16/2013) (expired 12/31/2013) Q2034 Influenza virus vaccine, split virus, for (Agriflu) (effective 07/01/2012) Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (AFLURIA) (effective 01/01/2011) Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (FLULAVAL) (effective 01/01/2011) Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (FLUVIRIN) (effective 01/01/2011) Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (Fluzone) (effective 01/01/2011) Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for (not otherwise specified) (effective 01/01/2011) G0008 Administration of influenza virus vaccine G0009 Administration of pneumococcal vaccine Medicare Covered for Hepatitis B Vaccines listed below are eligible for Medicare Part B coverage if there has been a documented exposure, injury or risk factor. For Hepatitis B, coverage is limited to those who are at high or intermediate risk of contracting Hepatitis B. High risk groups are identified as: ESRD patients Hemophiliacs who receive Factor VIII or IX concentrates Clients of institutions for the mentally retarded Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 3

4 Persons who live in the same household as a hepatitis B virus (HBV) carrier Homosexual men Illicit injectable drug abusers Persons diagnosed with diabetes mellitus. (Rev. 170, ) Intermediate risk groups are identified as: Staff in institutions for the mentally retarded Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work (V05.3) Code Description Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for Hepatitis B vaccine, adolescent (2 dose schedule), for Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for Hepatitis B vaccine, adult dosage, for Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for G0010 Administration of hepatitis B vaccine Medicare Covered for Tetanus Vaccine The below injections are covered when given for an acute injury to a person who is incompletely immunized. When the tetanus booster is given to a patient in the absence of an injury, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventive treatment) Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for Tetanus toxoid adsorbed, for Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for Medicare Covered for Rabies Vaccine Rabies is a disease that is carried by animals and transmitted by a bite or scratch. When administering a rabies vaccine to a human who has had an encounter with an animal that is at high risk for rabies, should be billed with the appropriate ICD-9 diagnosis code for the exposure Rabies vaccine, for Rabies vaccine, for intradermal use Medicare Covered for Administration of Tetanus and/or Rabies Vaccines Administration codes listed below for the tetanus and rabies vaccinations must also meet coverage criteria Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered (effective 01/01/2011) Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) (effective 01/01/2011) Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 4

5 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Medicare Non-Covered Vaccinations listed below are never covered by Medicare Part B or Medicare Part D Adenovirus vaccine, type 4, live, for oral use Adenovirus vaccine, type 7, live, for oral use Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose schedule, for intramuscular (Effective date 02/01/2015) Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine (Hib- MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use Influenza vaccine, inactivated, subunit, adjuvanted, for (code effective 01/01/2013) (Pending FDA approval) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for ( covered until 12/31/2010 then non-covered) Influenza virus vaccine, pandemic formulation, live, for intranasal use Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use (Pending FDA approval) Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for Influenza virus vaccine, pandemic formulation, split virus, for Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for (code effective 01/01/2013) (Pending FDA approval) Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S. military) Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for Cholera vaccine for injectable use Plague vaccine, for Japanese encephalitis virus vaccine, inactivated, for Hepatitis B vaccine, adult dosage (2 dose schedule), for (code effective 01/01/2013) (Pending FDA approved) Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for S0195 Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from 5 years to 9 years of age who have not previously received the vaccine Medicare Possibly Covered (Part D) Influenza Vaccinations listed below are never covered by Medicare Part B however may be covered by Medicare Part D Prescription Drug Coverage (reference the applicable formulary) Influenza virus vaccine, split virus, preservative-free, for intradermal use (for ages 1-17 yrs and > 64 yrs) Influenza virus vaccine, live, for intranasal use (for age 1 or > 49 yrs) Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 5

6 Medicare Possibly Covered (Part D) All Others Vaccination (Immunization) Vaccinations listed below are never covered by Medicare Part B however may be covered by Medicare Part D Prescription Drug Coverage (reference the applicable formulary) Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Anthrax vaccine, for subcutaneous or Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for (Effective date 01/01/2015) Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Hepatitis A vaccine, adult dosage, for Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use Typhoid vaccine, live, oral Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV- Hib-HepB), for (Effective date 01/01/2015) Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DtaP Hib IPV), for Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DtaP), when administered to individuals younger than 7 years, for Mumps virus vaccine, live, for subcutaneous use Measles virus vaccine, live, for subcutaneous use Rubella virus vaccine, live, for subcutaneous use Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 6

7 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Measles and rubella virus vaccine, live, for subcutaneous use Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Poliovirus vaccine, (any type[s]) (OPV), live, for oral use Poliovirus vaccine, inactivated (IPV), for subcutaneous or Varicella virus vaccine, live, for subcutaneous use Yellow fever vaccine, live, for subcutaneous use Diphtheria toxoid, for Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for Japanese encephalitis virus vaccine, for subcutaneous use Zoster (shingles) vaccine, live, for subcutaneous injection Unlisted vaccine/toxoid Questions and Answers Where is the Medicare sourcing for coverage of the Hepatitis B vaccine? I thought it was Q: covered for everyone. 1 The CMS sourcing for a list of indications that support payment of the Hepatits B series can be A: found at any of the locations listed in the References section of this policy. Q: Can I charge an administration fee? Yes. Administration fees for vaccines could be handled in the following manner: Before January 1, 2008: When a physician administers a Part D vaccine, the physician should use HCPCS code G0377 (linked to CPT code 90471) to bill the Part B local carrier for the administration fee of the vaccine. 2 A: January 1, 2008 and after: Part D vaccines, including the associated administration costs could be billed on one claim to the beneficiary or to the Part D plan, as stated in the preceding examples. *CMS believes that Part D vaccines, including the associated administration costs, should be billed on one claim for both in- and out-of-network situations. Part D vaccine administration costs are a component of the negotiated price for a Part D-covered vaccine. References Included (but not limited to): CMS LCD(s) Numerous LCDs CMS Article(s) Numerous articles CMS Benefit Policy Manual Chapter 15; 50 Drugs and Biologicals CMS Claims Processing Manual Chapter 17; 10 Payment Rules for Drugs and Biologicals, 40 Discarded Drugs and Biologicals Chapter 18 Preventive & Screening Services CMS Transmittals Transmittal 170, Change Request 8275, Dated 05/10/2013 (Updates to Medicare Coverage of Hepatitis B Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 7

8 Vaccine and its Administration and Medicare Coverage of the Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)) Transmittal 2693, Change Request 8249, Dated 05/02/2013 (New Influenza Virus and Hepatitis B Virus Vaccine Codes) Transmittal 2786, Change Request 8433, Dated 09/13/2013 (Influenza Vaccine payment Allowances Annual Update for Season) UnitedHealthcare Medicare Advantage Coverage Summaries Preventive Health Services and Procedures UnitedHealthcare Reimbursement Policies Discarded Drugs and Biologicals Self Administered Drug(s) UnitedHealthcare Medical Policies Vaccines MLN Matters Article MM8249, New Influenza Virus and Hepatitis B Virus Vaccine Codes Article MM8338, July 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS) Article MM8428, October 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS) Article MM8473, New Influenza Virus Vaccine Code Article MM9051, Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations Article SE0727 Revised, Reimbursement for Vaccines and Vaccine Administration Under Medicare Part D Article SE1431, Influenza (Flu) Resources for Health Care Professionals Others Department of Health and Human Services, Centers for Medicare & Medicaid Services, Preventive Services, CMS Website Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 Correct Coding Initiative Medicare Fee-For-Service Preventative Service Quick Reference Sheet: Medicare Immunization Billing (Seasonal Influenza Virus, Pneumococcal, and Hepatitis B), CMS Website Medicare National Coverage Determinations Manual CMS Website New and Revised Vaccine Codes for Early Release, AAPC Website History Date Revisions 04/08/2015 Annual review; Age limit verified for CPT code 90654, FDA approved for ages /14/ new codes added to the policy CPT codes 90620, 90621, and CPT code has gained FDA approval and will be moved to the payable section 04/09/2014 Annual review CPT codes 90653, 90687, and moved from the respective covered sections back to the non-covered sections as this remains as pending FDA approval- Vaccines that are described by codes 90653, 90685, 90687, 90688, and are currently pending Food and Drug Administration (FDA) approval per MLN Matters Number: MM8249 Medicare contractors shall deny claims for vaccines containing codes 90653, 90685, 90687, 90688, and if vaccines described by these codes have not obtained approval from the FDA by October 1, /06/2014 CPT code moved from Non-Covered section to the Medicare Covered for Hepatitis B section 12/17/2013 Q2033 no longer valid/payable 12/31/ /11/2013 Per MLN 8473 HCPCS code Q2033 effective date is to be corrected from 01/01/2013 to now state 07/01/2013 CPT code was added with effective date of coverage 01/01/2014 Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 8

9 12/03/2013 Added additional resource and information regarding administration fees for vaccines 11/20/2013 Moved the following CPT codes from the Medicare Non-Covered section to the appropriate covered section:90653 (coverage effective 01/01/2013) (Not FDA approved), (coverage effective 11/20/2013) (FDA approved as of 11/20/2013), (coverage effective 01/01/2013) Fluzone (Influenza virus vaccine) was approved by the FDA on June 7, 2013, (coverage effective 01/01/2013) (FDA approved as of 12/14/2012), (coverage effective 01/01/2013) (Not FDA approved), (coverage effective 01/01/2013) (FDA approved on 8/16/2013) Moved the following CPT codes from the covered section to the Medicare Non-Covered Section: ( covered until 12/31/2010 then non-covered), 90723, 90738, /04/2013 Administrative updates 08/24/2013 Administrative updates 06/27/2013 As of 05/10/2013, Medicare Part B added the risk criteria for Persons diagnosed with diabetes mellitus to their coverage of Hepatitis B vaccines 04/29/2013 As of 04/29/2013, CPT Influenza virus vaccine, live, for intranasal use had age criteria noted as removed effective 01/01/2012 in error Error was realized and the descriptor was corrected to include the age criteria (for ages 2 yrs 49 yrs - age criteria added effective 05/01/2011) 01/07/2013 Added NEW CPT codes 90653, 90672, 90685, 90686, 90687, 90688, and Added expiration dates to CPT codes 90665, 90701, and /30/2012 Administrative udpates 05/30/2012 Administrative udpates 04/30/2012 Policy re-written to include new CPT codes Moved from Never covered B but covered D to Never covered B or D Added age criteria to and Moved 90661, 90664, 90666, 90667, and from always covered B to Never covered B or D 04/24/ moved from the Never Covered Part B or D to Provisional coverage for Rabies 11/18/2010 Administrative updates 10/01/2009 Administrative updates Proprietary information of UnitedHealthcare. Copyright 2015 United HealthCare Services, Inc. Page 9

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