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Effective March 19, 2020, and until further symbicort allergic reaction notice, the Commission no longer accepts any hand or messenger can i buy symbicort over the counter delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of anti inflammatory drugs. See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, DA 20-304 (March 19, 2020). Https://www.fcc.gov/​document/​fcc-closes-headquarters-open-window-and-changes-hand-delivery-policy.

People with Disabilities. Contact the FCC to request reasonable accommodations (accessible format documents, sign language interpreters, CART, etc.) by email. FCC504@fcc.gov or phone. 202-418-0530 or TTY.

202-418-0432. For detailed instructions for submitting comments and additional information on the rulemaking process, see the SUPPLEMENTARY INFORMATION section of this document. Start Further Info Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is a summary of the Commission's further notice of proposed rulemaking (FNPRM) in WC Docket No.

18-336, adopted on April 22, 2021 and released on April 23, 2021. The full text of the document is available at https://docs.fcc.gov/​public/​attachments/​FCC-21-47A1.pdf. To request materials in accessible formats for people with disabilities (e.g., braille, large print, electronic files, audio format, etc.) or to request reasonable accommodations (e.g., accessible format documents, sign language interpreters, CART, etc.), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice) or (202) 418-0432 (TTY).

Synopsis I. Further Notice of Proposed Rulemaking A. Text-to-988 Can Save Lives 1. In this FNPRM, we tentatively conclude that text-to-988 functionality will greatly improve consumer access to the National Suicide Prevention Lifeline (Lifeline), particularly for at-risk populations, and thereby save lives.

We seek comment on this tentative conclusion, and on the benefits of text messaging as a means to facilitate access to the critical mental health resources offered by the Lifeline generally. 2. We tentatively conclude that ensuring that Americans in crisis can text 988 is likely to save lives. In the 988 notice of proposed rulemaking, the Commission observed that “Americans, particularly younger Americans, increasingly rely on texting to communicate,” and sought comment on how to account for this fact in establishing 988 as a nationwide 3-digit code for the Lifeline.

In response, numerous experts in mental health and other fields have submitted comments in this proceeding underscoring the importance of texting as a vital communications medium by which many individuals may wish to obtain crisis counseling. Further, many of these commenters noted that texting is particularly important for “members of vulnerable communities such as young people, low-income individuals, members of the LGBTQ community, and individuals who are deaf and hard of hearing.” We seek comment on our tentative conclusion and the assertions of these commenters regarding the importance of texting as a means to access the lifesaving resources offered by the Lifeline. 3. Just as “Americans in crisis are in need of an easy-to-remember number to access the Lifeline's potentially life-saving resources” by telephone, in our preliminary view Americans have a similarly strong need for an easy-to-remember number to reach the Lifeline by text.

Because stakeholders will widely advertise 988 as the telephone number for the Lifeline, we preliminarily believe that providing text access at the same number will generate synergies that enhance the value of efforts to promote 988. Conversely, we fear that if text-to-988 is not available, Americans in crisis may be confused by efforts to promote 988 as the Lifeline's telephone number and mistakenly believe that they can reach the Lifeline by texting 988, putting lives at risk. We seek comment on this preliminary analysis. 4.

As the Commission noted in the 988 Report and Order, young people are disproportionately at risk for mental health crises. They are also more likely to be most comfortable communicating via text. According to the National Alliance on Mental Illness, “[n]early 95% of teens have access to smart phones and say that texting is the primary way that they connect.” For this reason, the International Council for Helplines describes the increasing use of “chat and text services. .

. For those who are in a mental health crisis,” pointing to a recent survey indicating that “75% of millennials prefer texting over talking.” According to Mental Health America, “[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,” including a study finding that young people “were more likely to forgo psychological support than talk in person or over the phone.” As a result, Mental Health America argues, the “data strongly support[ ] the implementation of texting for providing resources to individuals experiencing suicidal ideation.” We seek comment on these views and whether adopting a text-to-988 mandate would provide particular benefits for young Americans. Are young people more inclined to seek help by text than by telephone, and if Start Printed Page 31405so, would making it easier to text the Lifeline save lives?. 5.

In our preliminary view, facilitating Lifeline accessibility by text message to 988 is also likely to provide significant benefits to many other at-risk communities as well, further justifying our proposed mandate. As the Commission explained in the 988 Report and Order, a broad range of American communities are disproportionately impacted by suicide, including Veterans, LGBTQ individuals, racial and ethnic minorities, and rural Americans. Many members of these affected communities may prefer to seek help through text messages. For example, Mental Health America reports that data they collect demonstrate that individuals “who identify as Black or African American are more likely to report that they would like to receive a phone number they can immediately call or text for help” than members of any other race or ethnicity.

Do commenters agree with Mental Health America that making crisis counseling services available via text message “may mean the difference between accessing psychological support and forgoing it, especially among youth of color?. € Is Mental Health America correct that easy access to crisis services via text may be the difference between seeking and forgoing help for such groups, and if so would use of a 3-digit dialing code for the Lifeline make a significant difference in widespread understanding that such crisis services are available?. 6. Indeed, demographic evidence regarding usage of currently available non-governmental text and chat options indicate that texting is a particularly valuable means to obtain help, not only for young people, but also for many members of low income, minority, and other communities that are disproportionately impacted by mental health crises.

Several commenters in this proceeding have pointed to the successes that private non-profit services like the Trevor Project have had in providing crisis counseling to at-risk communities through text messages, offering that their experiences demonstrate the need to provide text access to 988. In addition, as one commenter to the 988 notice of proposed rulemaking argued, adding text access to 988 could allow the Lifeline and Veterans Crisis Line “to more efficiently route those in need to specialized services,” further leveraging the expertise of organizations like the Trevor Project, which provides mental health support and counseling specific to the needs of LGBTQ youth. We preliminarily agree with this assessment and believe that establishing text access to 988 will complement the important work already being done by these and other private sector organizations, and further facilitate access to the lifesaving resources offered by the Lifeline and Veterans Crisis Line. We seek comment on these views and on the benefits of text-to-988 for at-risk groups.

Are there additional at-risk communities that may benefit from texting as an option to access the Lifeline?. 7. Likewise, we preliminarily believe that our tentative conclusion is further justified because implementing text-to-988 capability will provide substantial benefits for individuals with disabilities who uniquely rely on text-based media to communicate. As the Communications Equality Advocates and others note, texting is an indispensable means of communication for individuals with disabilities.

These individuals have increasingly adopted widely available text messaging platforms such as those offered by CMRS providers and interconnected text messaging services in lieu of specialized legacy devices. Further, texting may be the only means for such individuals to contact 988 directly and efficiently. Access to telecommunications for individuals with disabilities is a longstanding Commission priority and statutory obligation, and facilitating access to 988 for deaf and hard of hearing individuals is a particularly important policy objective in light of studies finding a significantly increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. We seek comment on these views and whether our proposal would ease access to lifesaving counseling for individuals with disabilities.

Do commenters agree with the Communications Equality Advocates that the ability for individuals normally using text for the bulk of their communications, including people with disabilities, to access trained mental health professionals using text-to-988 will be of “paramount importance”?. Currently, how do people with disabilities reach the Lifeline?. How would texting grant access or enhance their ability to communicate with the Lifeline?. We seek comment on whether texting would be more accessible than the options currently available, including the Lifeline's online chat portal.

8. We tentatively conclude that the potential lifesaving benefits of expanding access to suicide prevention and mental health crisis services for all Americans—and particularly the at-risk groups discussed above—justifies a text-to-988 mandate, and we seek comment on this view. The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would “help increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.” We preliminarily believe that establishing text access to 988 will further advance these important objectives by providing mental health crisis counseling through a nationally available, easy-to-remember number that Americans will also associate with the telephonic Lifeline. Do commenters agree with the Communications Equality Advocates that individuals in crisis “are likely to first use their preferred, familiar mode of communication to reach out for help?.

€ We seek comment on this analysis, and on our proposed conclusion that a text-to-988 mandate is likely to offer substantial, lifesaving benefits to all Americans affected by mental health crises, particularly for many members of at-risk communities. Is a text-to-988 mandate likely to have a significant impact on the likelihood of Americans considering suicide or in a mental health crisis to contact the Lifeline?. Would mandating text-to-988 amplify the benefits of promoting 988 as the telephone number for the Lifeline?. What are the costs or drawbacks to our proposal?.

9. In our preliminary view, the Lifeline's soft launch of a texting capability is a significant changed circumstance that supports mandating text-to-988. When the Commission adopted the 988 Report and Order, the Lifeline was not capable of receiving or responding to text messages. The Commission, stating that it has no authority to require the Lifeline to develop texting capability, deferred “consideration of mandating text-to-988 at this time so that we could revisit the issue promptly should the Lifeline develop integrated texting.” Now, the Lifeline is capable of responding to texts sent to the Lifeline.

The Lifeline's ability to respond to texts significantly strengthens the case for imposing a text-to-988 mandate on providers. We seek comment on this evaluation. 10. We preliminarily expect many of the same lifesaving benefits from texting to 911 to accrue from texting to 988.

In its comments in support of adopting a text-to-988 requirement, CTIA notes that text-to-911 functionality “has saved countless lives and enabled public safety to keep pace with the modern Start Printed Page 31406communications preferences of consumers.” Given the parallels between the Commission's efforts to promote text access to 911 and our proposals in this FNPRM, are there lessons learned in the context of establishing text-to-911 capability that would be instructive here?. CTIA states that there are “significant technical and policy differences between the national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.” For example, unlike calls to 911, which carriers route to one of thousands of local PSAPs across the country based on the caller's geographic location, all calls to 988 are routed to a central toll free number, and are then directed within the Lifeline network to a local crisis center. How might these or other differences between the 911 and 988 networks affect our proposal to adopt a text-to-988 requirement?. B.

Proposed Implementation of Text-to-988 1. Scope of Text-to-988 Requirement 11. Text Formats. We seek comment on an appropriate scope of text messages that covered text providers must transmit to 988.

At present, the Lifeline is capable of receiving text messages sent to the existing 10-digit number in “short message service” (SMS) format. The Commission's Truth in Caller ID rules define the term `short message service' or SMS as “a wireless messaging service that enables users to send and receive short text messages, typically 160 characters or fewer, to or from mobile phones and can support a host of applications.” We recognize, however, that our federal partners may incorporate additional capabilities for receiving and responding to text messages in the future. We seek to adopt a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers by requiring support of formats that the Lifeline is not yet capable of receiving. To that end, we propose (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support.

And (2) directing the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number. We seek comment on this proposal in detail below. 12. First, we propose to define the outer bound of text messages that covered text providers may be required to transmit to 988 based on the definition of “text message” that Congress enacted in 2018 in the context of Truth in Caller ID requirements.

The term “text message” (i) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code. (ii) includes a [SMS] message and a multimedia message service (commonly referred to as `MMS') message. And (iii) does not include—(I) a real-time, two-way voice or video communication. Or (II) a message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in clause (ii).

The Commission's Truth in Caller ID rules define MMS as “a wireless messaging service that is an extension of the SMS protocol and can deliver a variety of media, and enables users to send pictures, videos, and attachments over wireless messaging channels.” We seek comment on this proposed scope. We believe this definition has several advantages—it incorporates multimedia messages. It is not limited to specific technologies. And it reflects a recent determination by Congress, albeit in a different policy context.

For the purpose of our text-to-988 rules, we propose adding “or 988” to the phrase “10-digit telephone number or N11 service code” so that text messages from the Lifeline identified by the 3-digit code 988 are included within the scope of covered text providers' obligations, and we seek comment on this proposal. We seek comment on whether using the Truth in Caller ID definition appropriately sets an outer bound that would achieve our goals of adopting a forward-looking, flexible scope that can expand with the capabilities of the Lifeline without unnecessarily burdening covered text providers. 13. We note that the Truth in Caller ID statutory definition of “text message” excludes “real-time, two-way voice or video communications,” as well as “messages sent over.

. . IP-enabled messaging services to another user of the same messaging service.” If we adopt the Truth in Caller ID definition, we seek comment on how we should interpret each of these two exclusions here. Is there any reason to adopt a different interpretation of the relevant exclusions in this context compared to the Truth in Caller ID context?.

€ Would adopting the Truth in Caller ID definition of “text message,” with the exclusions specified above, prevent us from possibly adding “next-generation” text messages to our requirements in the future?. 14. We also seek comment on alternative outer scopes of required texts. For instance, should we adopt the scope of our text-to-911 rules, which require providers to route “a message, consisting of text characters, sent to the short code `911' and intended to be delivered to a PSAP by a covered text provider, regardless of the text messaging platform used”?.

In the Text-to-911 Second Report and Order, the Commission identified SMS and MMS messages as examples of text messages included within the scope of this proposed rule. We seek comment on whether the Truth in Caller ID definition, the text-to-911 definition, or another definition offers the best model here. We note that the Truth in Caller ID model is newer than the text-to-911 definition, originates with Congress rather than the Commission, and unlike the text-to-911 definition explicitly includes images, sounds, and other non-textual information. On the other hand, the Commission developed the text-to-911 definition in a more analogous policy context than the Truth in Caller ID definition.

Do these or other considerations suggest that one or the other model is superior?. 15. Should we ensure that any definition we adopt encompasses next-generation forms of text messaging, such as MMS, Rich Communications Services (RCS), and/or real-time text (RTT), and what modifications—if any—would we need to make to the definitions we are considering to ensure that such forms are within our proposed scope?. RCS has been described as a “successor protocol” to SMS, or as “next-generation” SMS.

What are the fundamental differences between SMS, MMS, and RCS?. How would the costs to implement SMS, MMS, and RCS differ?. The Commission has previously concluded that “messages sent over other IP-enabled messaging services that are not SMS or MMS—such as [RCS]—are excluded from” the Truth in Caller ID definition of text message “to the extent such messages are sent to other users of the same messaging service.” Would it be necessary to modify the Truth in Caller ID definition for our purposes to ensure that it includes RCS or other next-generation services?. 16.

We also seek comment on whether we should ensure that our proposed outer bound definition of text message encompasses RTT. Telecommunications for the Deaf and Hard of Hearing, Inc., et al. Have urged us to mandate the ability to reach 988 by RTT, noting that the Commission “has acknowledged the benefits of RTT in crisis situations such as `allow[ing] for interruption and reduc[ing] the risk of crossed messages Start Printed Page 31407because the. .

. Call taker is able to read the caller's message as it is being typed, rather than waiting until the caller presses the `send' key.” We seek comment on this assertion and other potential benefits and drawbacks of RTT to 988. We note that pursuant to the 2016 RTT Order, all wireless service providers are permitted to support RTT on their IP networks for purposes of 911 compliance (and for purposes of complying with the general accessibility requirements of Parts 6, 7, and 14 of the Commission's rules) as an alternative to supporting TTY communications over IP. In light of the deployment of such RTT capabilities in wireless IP networks, are there any impediments to wireless service providers routing RTT texts to the 988 number, in the event that Lifeline chooses to support RTT?.

Do newer text messaging protocols like RTT and RCS represent a significant portion of the text messaging ecosystem, or are they likely to in the near future?. Are consumers likely to expect the ability to use these kinds of platforms to send text messages to 988?. Do these texting solutions make texting more accessible for individuals with disabilities?. Are there other reasons to include, or exclude, these types of applications from our definition?.

Are there any text message formats that we should specifically exclude from the definition we adopt?. For example, in crafting the text-to-911 rules, the Commission chose to exclude from its requirements a variety of services, including “relay service. . .

, mobile satellite service (MSS), and in-flight text messaging services,” as well as “text messages that originate from Wi-Fi only locations or that are transmitted from devices that cannot access the CMRS network.” Should we adopt any similar exclusions here?. 17. Second, we seek comment on how to structure our delegation to the Bureau to ensure that covered text providers support formats within the scope of the definition we adopt that the Lifeline can receive. We propose, as an initial matter, requiring covered text providers to support transmission of SMS messages to 988, since that is what the Lifeline can presently receive.

We further propose directing the Bureau, after consultation with our federal partners at SAMHSA and the VA, to issue a Public Notice no less frequently than annually proposing and seeking comment on requiring covered text providers to transmit any new message formats to 988 that the Lifeline can receive and that are within the scope of the definition we adopt. If the Bureau proposes requiring implementation of a new message format, we further propose directing the Bureau, after notice and comment, to issue a second Public Notice, requiring covered text providers to transmit the new message format to 988 by a fixed deadline that we specify unless the record demonstrates that implementation is not technically feasible. We seek comment on this proposal. Does it appropriately balance the need for expedient implementation with avoiding unduly burdening covered text providers with implementing formats that the Lifeline cannot receive?.

Should we require the Bureau to issue a Public Notice more or less often than annually?. Or is there another mechanism, such as one similar to the Commission's Text-to-911 PSAP registry, whereby PSAPs issue a valid request for texting service from covered text providers, that we should consider?. Is technical feasibility an appropriate standard for exclusion, or do commenters recommend a different standard?. Should we have a standard for exclusion by the Bureau at all?.

If we do not have a standard for excluding certain technologies, is notice and comment necessary?. What is an appropriate implementation deadline for us to specify after the Bureau issues its Public Notice requiring implementation?. For instance, would six months be sufficient?. Should we instead allow the Bureau flexibility to set an appropriate deadline?.

Should we provide any further direction to the Bureau regarding the evaluation we propose to require?. 18. We also seek comment on structuring the scope of covered text messages differently. For instance, should we simply adopt a definition of “text message” and require covered text providers to support all such formats, regardless of whether the Lifeline can support that format presently?.

Should we adopt a narrower definition of “text message” that conforms to what the Lifeline can support at present?. While we appreciate the simplicity of either of these approaches compared to our proposal, how would commenters address our concern that the former is unnecessarily burdensome, and the latter is not adequately future-proofed?. 19. Covered Text Providers.

We propose to apply our text-to-988 requirement to “covered text providers” as that term is defined in the text-to-911 rules, to “include[ ] all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.” We note that the term “covered text provider” used in this notice of proposed rulemaking differs from the term “covered providers” used in the rules the Commission adopted in the 988 Order, which refers to all telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers. We seek comment on this proposal, and on any alternative approaches to the scope of entities that must establish text-to-988 transmission capability. For example, if we can apply the definition of “text message” in the Truth in Caller ID rules to texting to 988, should we apply our text-to-988 rules to providers of “text messaging services,” as defined in section 227 of the Act and our Truth in Caller ID rules?.

In that context, we define “text messaging service” as “a service that enables the transmission or receipt of a text message.” Is the Truth in Caller ID model preferable, for instance because it may incorporate a broader range of providers that support text messaging service, or is our proposal preferable, for instance because it is more specific?. We also seek comment on other possible models and scopes of covered providers. Would using “CMRS providers” exclude services over certain spectrum bands or non-switched wireless services that transmit text messages to 988, and should we instead include “wireless carriers,” or a different term, in our definition of “covered text providers?. € 20.

Interconnected Text Messaging Services. In adopting the text-to-911 rules, the Commission observed that there are a variety of widely available text messaging services and platforms with different technological capabilities, including SMS, MMS, and “over-the-top” (OTT) applications delivered over internet protocol (IP)-based mobile data networks. As the Commission explained in the Text-to-911 Second Report and Order, “SMS requires use of an underlying carrier's SMS Center (SMSC) to send and receive messages from other users” while “[MMS]-based messaging makes use of the SMSC but also involves the use of different functional elements to enable transport of the message over IP networks.” A third category, OTT applications, may be offered by CMRS providers or third parties and allow consumers “to send text messages using SMS, MMS or directly via IP over a data connection to dedicated messaging servers and gateways.” These OTT services, which are often downloaded through mobile app stores, are increasingly popular with consumers and may be interconnected with the publicly Start Printed Page 31408switched telephone network (PSTN) or not. For purposes of the Commission's text-to-911 rules, interconnected text messaging applications enable consumers to “send text messages to all or substantially all text-capable U.S.

Telephone numbers and receive text messages from the same,” while non-interconnected applications “only support communication with a defined set of users of compatible applications but do not support general communication with text-capable telephone numbers.” The Commission's text-to-911 rules include interconnected text messaging services but exclude non-interconnected applications because they do not provide the ability to communicate with text-capable U.S. Telephone numbers. 21. As in the text-to-911 rules, we propose to apply our text-to-988 requirements to interconnected text messaging services, thereby excluding non-interconnected applications from the requirements.

We seek comment on this approach. This approach is also analogous to the Commission's decision in the 988 Report and Order to apply to “providers that access the [PSTN] on an interconnected basis to reach all Americans” and any “providers that access the [PSTN] on an interconnected basis to reach all Americans.” We note that the Commission's Truth in Caller ID rules provide an exemption for messages “sent over an IP-enabled messaging service to another user of the same messaging service, except [for an SMS or MMS message],” which similarly operates to exclude non-interconnected text messaging services. Since the services provided by the Lifeline require two-way communication and, by definition, non-interconnected text messaging applications cannot support two-way texting with “all or substantially all text-capable U.S. Telephone numbers,” we believe it is unlikely that these services would be technically capable of supporting text-to-988 functionality.

We seek comment on this view. Are there any tools available to the Commission to mitigate the potential for consumer confusion regarding the availability of text-to-988 across different text messaging platforms and technologies, particularly with respect to non-interconnected text messaging applications?. 2. Routing Texts to 988 22.

We propose to require that covered text providers route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK), and we seek comment on this proposal. This proposal is consistent with the Commission's decision for routing calls to 988 in the 988 Report and Order. In the 988 Report and Order, the Commission required “that service providers transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline,” finding that a centralized routing solution will allow for faster implementation of the 988 3-digit dialing code, lower costs to maintain 988 routing, and provide continued easy access to Lifeline by callers with disabilities. We preliminarily believe that there are similar benefits to routing texts to 988 to a single, centralized number and seek comment on this view.

23. There is support in the record thus far for routing to the Lifeline. CTIA supports directing texts sent to 988 to the Lifeline as a “central point for receiving such communications,” consistent with the Commission's mandate for routing 988 voice calls. Vibrant Emotional Health, the administrator of the Lifeline, argues in support of text-to-988 functionality integrated into the current Lifeline structure for routing voice and chat services, with oversight squarely within the role of the Lifeline's administrator.

We seek comment on these assessments. 24. We anticipate that requiring covered text providers to route to a single destination provides SAMHSA and the VA with flexibility to develop their own routing solutions among the local crisis centers, including adding new crisis centers in the future, as compared to requiring covered text providers to implement additional updates or routing changes as more centers are added. Callers to 1-800-273-8255 (TALK) can reach the Veterans Crisis Line by pressing option 1 to connect with one of three linked call centers in New York, Georgia, or Kansas.

For other calls, calls to the Lifeline from anywhere in the United States are routed to the closest certified local crisis center according to the caller's area code or, should the closest center be overwhelmed by call volume, experience a disruption of service, or if the call is placed from part of a state not covered by Lifeline's network, the system automatically routes calls to a backup center. We seek comment on this preliminary analysis. Do the current obligations to route voice calls to 988 to the Lifeline 10-digit number offer any opportunities for streamlining implementation or reducing costs associated with routing texts to 988 to the same number?. 25.

In the alternative, we seek comment on whether instead to follow a model more comparable to the text-to-911 architecture, whereby covered text providers route directly to a PSAP by requiring routing directly to a Lifeline local crisis center or to a Veterans Crisis Line crisis center. We anticipate that this approach would be significantly more costly than centralized routing and seek comment on this preliminary view. Is it easier to route texts to a single number than to individual crisis centers?. As the Veterans Crisis Line is not currently set up for geographic distribution, would this architecture be appropriate for messages by Veterans or Service Members?.

Are covered text providers able to leverage existing text-to-911 systems to reduce costs if required to route texts to 988 directly to local crisis centers?. In the 988 Report and Order, the Commission recognized that some commenters expressed there may be benefits to routing voice calls to individual crisis centers, such as familiarity with a caller's area and potentially easier coordination with local emergency services, but ultimately concluded that the advantages associated with routing to a single number outweighed the benefits of localized routing. Does that rationale apply here?. Are there benefits to routing texts to the individual crisis centers that are unique to text messages, such as providing localized support to the public in the vicinity of the crisis center?.

What are the costs or drawbacks to covered text providers to route texts to the Lifeline 10-digit number versus the local crisis centers?. Which approach will lead to speedier implementation, and how should that impact our analysis?. Is there another alternative approach, other than centralized routing or routing by crisis center, that we should consider?. 26.

Currently, Veterans and Service Members may dial the Lifeline to reach the Veterans Crisis Line via voice call, but the Lifeline texting service and the VA's short code texting service require contacting separate numbers. How should we account for this distinction in evaluating what rules to adopt to ensure that Veterans, Service Members, and their families are able to reach the Veterans Crisis Line directly and promptly?. We seek comment on whether and how we can act to facilitate integration of the Veterans Crisis Line's separate short code-based texting service into text-to-988 routing. Are there specific actions that the Commission should take to allow users to text 988 and reach both the Lifeline and Veteran-specific assistance?.

For instance, should we require covered text providers to provide an automated inquiry as to whether the texter is a Veteran or Service Member and route Start Printed Page 31409the text to either the existing Lifeline number or the existing short code for Veterans depending on the response?. Alternatively, would it be feasible to immediately prompt individuals texting to 988 to reply with the number “1” or “Vet” to be routed to the Veterans Crisis Line, similar to the experience for voice callers?. Are other prompts preferable?. We seek comment on possible solutions to ensure that texts are routed to the proper counseling services via the Lifeline or the Veterans Crisis Line, including input on technical feasibility, ways to minimize consumer confusion, and implementation costs.

Should other text or chat services be integrated into 988 text routing, and if so, how?. 27. We seek comment on whether we should require covered text providers to enable text-to-988 messages to include location information. As required by the National Suicide Hotline Designation Act of 2020, the Bureau will report to Congress on the costs and feasibility of providing location information with 988 calls on April 17, 2021.

In our preliminary view, given that we have not adopted a location mandate in the context of calls to 988, we believe it would be premature to adopt a mandate here, and we seek comment on this view. Does someone who sends a text message to 988 expect that their location will be transmitted to the Lifeline?. If consumers generally are aware that calls and texts to 911 include their location, would the same expectation apply to texts to 988?. Would including location information deter at-risk individuals from texting to 988?.

We seek comment on any complications inherent in this plan and on ways for covered text providers to work with SAMHSA and the VA to limit misrouting of texts. 3. Implementation Timeframe for Text-to-988 28. Uniform Nationwide Deadline.

We seek comment on an appropriate implementation timeframe for requiring covered text providers to support texting to 988 on a nationwide basis. We preliminarily propose adopting a uniform nationwide deadline for implementation for all covered text providers and for all covered 988 text messages, as determined by the Bureau. In the 988 Report and Order, the Commission determined that the “rollout of 988 will be most effective if [it] set a single implementation deadline so that stakeholders can clearly and consistently communicate to the American public when 988 will be universally available.” We preliminarily believe that the same holds true here, and we seek comment on this view. Are there other benefits to a uniform nationwide implementation deadline?.

What drawbacks, if any, exist?. 29. Although we propose adopting a uniform nationwide deadline, we seek comment on whether we should adopt any extensions or exemptions for certain classes of providers or categories of text messages. Should we adopt any extensions or exemptions for smaller, rural, or regional covered text providers?.

If so, under what circumstances would such exemptions be appropriate?. Are there unique technical considerations that necessitate different implementation timelines for certain covered text providers?. If so, what are they and why?. Are there any other considerations, such as any existing contractual obligations between our federal partners and other entities, that we should take into account in setting a deadline or deadlines?.

30. Appropriate Deadline. We observe that CTIA and other commenters have previously argued that the Commission should not mandate text-to-988 before the Lifeline is capable of receiving and responding to texts, in part because the Lifeline's readiness to receive and respond to text messages is crucial to implementing text-to-988 successfully. We seek comment on this assertion.

We also seek comment on CTIA's proposal to require covered text providers to “deliver text-to-988 to the Lifeline by July 16, 2022, or six months after the Lifeline demonstrates its readiness to accept text messages, whichever is later.” Is the Lifeline's pilot program sufficient to demonstrate that it is ready to accept text messages?. If not, how should we determine that the Lifeline has demonstrated readiness to accept text messages, both from a technical and operational standpoint?. How should we take into account the capabilities of the Veterans Crisis Line in establishing a deadline?. Understanding that the Lifeline and Veterans Crisis Line successfully accepting and responding to text messages to 988 will require coordination between several stakeholders, we emphasize that the Commission will continue to coordinate closely with our federal partners, SAMHSA and the VA, in their efforts to enable crisis centers to respond to text messages to 988 and establish a reasonable implementation timeframe for text-to-988.

We reiterate that the Commission does not wish to determine for SAMHSA how it allocates the Lifeline's resources, nor do we have the authority to require the Lifeline and its crisis centers to be capable of receiving and responding to text messages to 988. 31. We seek comment on whether the Commission should require all covered text providers to support text-to-988 by July 16, 2022, the same implementation deadline for telecommunications carriers, interconnected VoIP providers, and one-way VoIP providers to support voice calls to 988. Is this technically, economically and operationally feasible?.

Are there benefits to requiring a uniform implementation timeline for all voice and text communications to 988?. We observe that some covered text providers have already implemented voice calling to 988. For those providers, will requiring covered text providers to implement text-to-988 on the same timeline as voice calling to 988 create any efficiencies, such as reducing fixed costs?. Is there an expectation that once 988 is deployed nationwide for voice communications that texting to 988 will be similarly available?.

Will a uniform implementation deadline discourage covered text providers from potentially supporting text to 988 before July 16, 2022?. Are there other potential benefits or drawbacks to uniform implementation deadlines for providers supporting voice calling and texting to 988?. 32. Alternatively, we seek comment on whether we should separate the timeline for implementing text-to-988 from the implementation timeline for voice-to-988.

Is a phased-in approach preferable?. Would it be beneficial to consider balance of telecommunications activation needs and organizational response needs by SAMHSA and the VA?. Would it be less burdensome on providers working to implement 988 for voice calls in accordance with the 988 Report and Order?. Would a phased-in implementation timeline create consumer confusion regarding the availability of texting to 988?.

If phased-in implementation deadlines would create consumer confusion, would requiring certain covered text providers to implement text-to-988 more quickly minimize consumer confusion?. For example, if a covered text provider has already implemented voice calling to 988 and is advertising the availability of 988 to its customers, should the provider be required to implement text-to-988 before other covered text providers?. Are there other risks associated with a phased-in approach to an implementation timeline for voice and text communications to 988 as compared to uniform implementation timeline?. What, if any, phased-in deadlines should the Commission consider?.

33. We also seek comment on whether we should we adopt the same timeline for all covered text providers, regardless of the text messaging technology they use. Are there other preparedness concerns that we should take into Start Printed Page 31410consideration when determining an implementation timeframe?. 4.

Technical Considerations 34. We seek comment on the specific technical considerations for covered text providers and equipment and software vendors—including those providers who are rural or small businesses—necessary to implement text-to-988. We propose to allow covered text providers to use any reliable method or methods (e.g., mobile-switched, IP-based) to support text routing and transmission to 988, similar to text-to-911 implementation. We seek comment on this proposal.

35. Network Upgrades. We seek comment on possible upgrades covered text providers would have to make to their networks to support text-to-988 capability. Since we propose to allow covered text providers to use any reliable method or methods to support text routing and delivery to 988, are any necessary network hardware or software upgrades small in scope?.

What specific components would require upgrading?. Can the current solutions to enable text-to-911 capability be leveraged to support text-to-988, or are the implementation options for covered text providers to support text-to-988 significantly different?. CTIA notes “there are significant technical and policy differences between national 9-8-8 service that will be administered by the Lifeline and the local 9-1-1 services that are administered by thousands of PSAPs.” We seek comment on CTIA's view, especially with regard to any “significant” technical differences. Conversely, do commenters agree with Communications Equality Advocates that the costs to covered text providers for implementation of text-to-988 should be substantially lower than those associated with implementing text-to-911?.

We seek further comment on the potential integration of text-to-988 solutions with existing systems, as well as other network considerations specific to covered text providers to support text-to-988. 36. We also seek comment on whether there are unique network considerations for different text messaging service technologies within the proposed outer bound scope of text-to-988 service that impact implementation. CTIA comments that its member companies are “optimistic about the technical feasibility of supporting text-to-988,” provided that implementation is consistent with existing capabilities of native SMS messaging.

Do commenters agree?. Are there fewer network upgrades necessary to support SMS-only texts to 988?. What specific network upgrades would be required should we obligate covered text providers to support other text messaging formats, such as MMS, RTT, or RCS?. Given that the Commission has recognized MMS as “an extension of the SMS protocol,” would support for MMS messaging be comparably feasible to support for SMS?.

How does the evolution of texting services to new or future formats affect network upgrade options and implementation, and how should our rules account for such evolution?. Would requiring support for certain text messaging formats be more feasible for covered text providers to implement than others?. 37. We specifically seek comment on the technical implementation capability and network upgrades necessary for interconnected text messaging service providers.

Similar to the Commission's conclusion in the Text-to-911 proceeding, we anticipate that many interconnected text messaging service providers may choose to use a CMRS network-based solution to deliver texts to 988 and seek comment on this expectation. Have there been developments in text-to-911 delivery by interconnected text messaging service providers that such providers can use in text-to-988 implementation?. In the text-to-911 context, the Commission's rules state. To the extent that CMRS providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 911 text messages originating on such other covered text providers' application services.

Covered text providers using the CMRS network to deliver 911 text messages must clearly inform consumers that, absent an SMS plan with the consumer's underlying CMRS provider, the covered text provider may be unable to deliver 911 text messages. CMRS providers may migrate to other technologies and need not retain SMS networks solely for other covered text providers' 911 use, but must notify the affected covered text providers not less than 90 days before the migration is to occur. We seek comment on adopting this or a comparable requirement here. We recognize that text-to-911 network integration is necessary to facilitate a CMRS network-based solution, and we seek comment on whether the same integration is necessary for transmission of text-to-988 communications by other covered text providers using that solution.

We seek comment on the relationship between CMRS providers and interconnected text messaging service providers to maintain support and capability for text-to-988 service based on the technical solutions available. We emphasize that, as in the text-to-911 proceeding, even if we were to adopt a rule comparable to the text-to-911 rule above, we do not intend to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers. Further, similar to the Commission's position in the Text-to-911 Second Report and Order, if we adopt a rule comparable to the text-to-911 rule above, we propose concluding that it is the responsibility of the covered text provider using the CMRS-based solution to ensure that its text messaging service is technically compatible with the CMRS providers' SMS-based network and devices, and in conformance with any applicable technical standards. We seek comment on this proposal.

Finally, as in the text-to-911 context, if we adopt a rule comparable to the text-to-911 rule above, we propose requiring CMRS providers to make any necessary specifications for accessing their SMS networks available to other covered text providers upon request, and to inform such covered text providers in advance of any changes to these specifications. We seek comment on this proposal. 38. We also seek comment on specific technical considerations for covered text providers that are rural or regional providers, or small businesses.

Are there unique impediments or challenges to implementation that these types of providers face that warrant further consideration?. 39. Equipment Upgrades. We seek comment on possible equipment or software upgrades required for covered text providers to implement text-to-988.

What challenges will equipment (e.g., handsets, network infrastructure) and software vendors face with respect to the implementation and deployment of text-to-988?. For example, are upgrades required for operating systems, firmware, or other software on mobile devices to support text-to-988 capability?. Are there upgrades necessary by vendors that are beyond the covered text providers' control that require additional coordination?. Will new standards need to be defined to ensure interoperability?.

40. In the Text-to-911 proceeding, the Commission clarified that legacy devices that are incapable of sending texts via 3-digit codes are not subject to the text-to-911 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-911. If the device's text messaging software can be upgraded over the air to support a text to 911, however, then the Commission required the covered text provider to make the necessary software upgrade available. Should we include a Start Printed Page 31411similar exemption for legacy devices under any text-to-988 requirements we may adopt?.

Have circumstances changed in the past seven years such that we should adopt a different approach here?. 5. Cost Recovery 41. Consistent with the Commission's decision in the 988 Report and Order, we propose to require that all covered text providers bear their own costs to implement text-to-988 capability to the Lifeline 10-digit number.

As with call routing to 988, we do not anticipate any shared industry costs are necessary to implement text-to-988, in contrast to previous non-988 numbering proceedings where the Commission established a cost recovery mechanism. As proposed, costs to support text-to-988 would be borne by each provider, specific to the solutions each has adopted to route texts to 988 ultimately to the Lifeline's current toll free access number, presently 1-800-273-8255 (TALK). We seek comment on this proposal. 42.

We believe this approach promotes efficiency in implementation and avoids unnecessary administrative costs. Section 251(e)(2) of the Act states that “[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basis.” The Commission typically applies cost recovery mechanisms in situations involving some type of numbering administration arrangement, such as when the Commission hires a third party to develop a database for industry use, to ensure that the statutory cost neutrality requirements are met. Here, as with implementation of voice calls to 988, circumstances do not require establishment of a numbering administration arrangement as there will not be shared costs. Therefore, we believe the section 251(e)(2) requirements do not apply.

Furthermore, even if section 251(e)(2) applies, we believe it is satisfied if we require each provider to bear its own costs because each provider's costs will be proportional to the size and quality of its network. We seek comment on this analysis. 6. Bounce-Back Messages 43.

We seek comment on whether and in what circumstances to require covered text providers to send automatic bounce-back messages where text-to-988 service is unavailable. Throughout the ongoing roll-out of text-to-911 services across the U.S., the Commission has required covered text providers to send an automatic reply, or bounce-back, text message when a consumer attempts to send a text message to a PSAP by means of the 3-digit code “911” and the covered text provider cannot deliver the text because (1) the consumer is located in an area where text-to-911 is not available, or (2) the covered text provider either does not support text-to-911 generally or does not support it in the particular area at the time of the consumer's attempted text. Unlike in the text-to-911 context, where availability varies by geography and is based on whether the local PSAP can receive texts, our proposals herein would require covered text providers to support nationwide texting to the Lifeline via the 988 3-digit code on a uniform nationwide deadline. If we were to adopt our proposal, should we nonetheless require bounce-back messages?.

If so, when and under what circumstances?. Should we require covered text providers to make available bounce-back messages sooner than we require implementation of text-to-988?. Would requiring bounce-back messages be appropriate if we adopt a uniform nationwide deadline for text-to-988 capability later than July 16, 2022—the uniform nationwide deadline for covered providers to support calls to 988?. Would requiring bounce-back messages be appropriate if we adopt exemptions or extensions for some providers?.

44. We seek comment on the potential benefits and costs of a bounce-back requirement. In the text-to-911 context, the Commission determined that “there is a clear benefit and present need for persons who attempt to send emergency text messages to know immediately if their text cannot be delivered to the proper authorities,” noting that feedback where text-to-911 is not available may be lifesaving by directing a person to seek out an alternative means of communicating with emergency services. Is that the case here as well?.

Because some individuals with disabilities may rely exclusively on texting for communicating, are there unique benefits of a bounce-back requirement for these individuals?. Since the Commission designated 988 as the 3-digit dialing code to access the Lifeline, efforts have been underway to educate the public about using this 3-digit code to reach help by telephone in times of mental health crisis, including its availability for routing voice calls to the Lifeline by July 16, 2022. In the absence of a bounce-back, might such advertising confuse the public about the availability of texting to 988?. Would an automated bounce-back help to prevent such confusion?.

Are there other advantages to requiring covered text providers to send bounce-back messages for attempts to text 988 where service is unavailable?. Are any providers included under the proposed “covered text providers” definition currently sending bounce-back messages to texts sent to 988?. 45. What are the costs of requiring a bounce-back message?.

What work or upgrades would be necessary for text service providers to implement an automatic bounce-back reply?. Given that covered text providers must provide a bounce-back in circumstances in which text-to-911 is unavailable, would adding a comparable bounce-back message for 988 be easier than if that existing infrastructure were not in place?. Would requiring text service providers to build bounce-back capabilities deter resources from more rapid deployment of text-to-988?. 46.

We seek comment on how requiring bounce-back messages may impact the public's ability to seek help from the Lifeline in times of mental crisis. What are the potential benefits to receiving an automatic bounce-back message when text-to-988 service is unavailable?. Are there any drawbacks to the public of requiring covered text providers to send bounce-back messages when text-to-988 is not available?. One commenter contends that if at-risk texters receive a bounce-back message regarding the unavailability of services, “the risks of disengagement and adverse outcomes increase.” Do commenters agree with the assessment that an automatic bounce-back message will negatively impact individuals seeking help during a crisis?.

Would a bounce-back message have the effect of making the sender more discouraged, such that it that could increase, not decrease, the likelihood of suicide?. Alternatively, if there is no automatic reply, and the sender is left wondering whether the Lifeline received the text message, would that uncertainty also increase sender's likelihood of suicide?. We seek comment on whether the benefits of receiving an automatic bounce-back message outweigh the potential risk of disengagement. 47.

If we were to adopt a bounce-back requirement, we seek comment on the specific requirement we should adopt. To align with the scope of the proposed outer bound text-to-988 capability requirements, we propose that if we were to adopt a bounce-back requirement, we would require all covered text providers to provide automatic bounce-back messages to text messages, as defined by our outer bound Start Printed Page 31412proposal herein, sent to 988 where text-to-988 service is unavailable. We seek comment on this approach. Are there unique considerations for different technologies within the outer bound scope of text message that we should consider under our bounce-back message proposal, including such impact on technical implementation or costs?.

Should we consider requiring covered text providers to send automatic bounce-back messages in reply to messages outside the scope of the outer bound definition?. Are there additional text or chat service providers that offer services beyond the proposed outer bound definition that we should include within the scope of our proposed bounce-back requirement?. Should we limit any bounce-back requirement to covered text providers, as proposed, or should the requirement sweep more broadly?. CTIA asserts that text-to-988 implementation should be consistent with existing SMS capabilities.

Should any bounce-back requirement we may explore likewise remain consistent with SMS?. Is sending a bounce-back message in response to texts to 988 feasible on legacy SMS systems?. We seek comment on the impact including other text or chat service providers, or other forms of messages, may have on the implementation costs, technical feasibility, and timeframe for our proposed bounce-back message requirements. 48.

Should we adopt a bounce-back requirement, we seek comment on whether and how to expand on the circumstances in which a covered text provider must provide a bounce-back message due to unavailability of text-to-988. In the text-to-911 context, when a customer is roaming away from his or her “home network” (i.e., the network of the customer's mobile carrier), the CMRS provider operating the customer's home network is nonetheless responsible for providing a bounce-back message when required. And the provider operating the network on which the customer is roaming must not impede the bounce-back response by the home network operator. We seek comment on adopting a similar requirement here.

Additionally, we anticipate that there may be circumstances in which the Lifeline is unable to receive and respond to texts, including where demand may exceed its capacity to respond. In instances amounting essentially to a “busy signal” for text delivery, are covered text providers capable of determining that the text cannot be delivered to 988?. Would covered text providers be able to determine if a text to 988 is undeliverable due to the Lifeline's inability, whether temporary or sustained, to receive and respond to the texts?. Or should we establish a mechanism whereby the Lifeline may inform providers of a temporary suspension of text-to-988 service, and should the bounce-back requirement apply until the suspension is lifted?.

Lastly, we seek comment on considerations, either within the control of the covered text provider or the Lifeline's administrators, in which a message from an individual in crisis attempting to reach 988 may not be delivered, and therefore may benefit from receipt of a bounce-back message directing the individual to contact 988 by alternative means. Are there additional circumstances where we should require covered text providers to send bounce-back messages in response to 988 texts?. 49. If we were to adopt a bounce-back requirement, we propose to adopt the same exceptions to our bounce-back notification requirement for text-to-988 as currently exist for the Commission's text-to-911 rules.

If we adopt that same approach, a covered text provider would not be required to provide an automatic bounce-back message when. (1) Transmission of the text message is not controlled by the provider. (2) a consumer is attempting to text 988, through a text messaging application that requires CMRS service, from a non-service initialized handset. (3) the text-to-988 message cannot be delivered due to a failure in the Lifeline's routing network that has not been reported to the provider.

Or (4) a consumer is attempting to text 988 through a device that is incapable of sending texts via 3-digit codes, provided that the software for the device cannot be upgraded over the air to allow text-to-988. We seek comment on this approach. Are there other situations where a covered text provider should not be required to send bounce-back messages to consumers attempting to text to 988?. Furthermore, we seek comment on the circumstances in which the provider of a pre-installed or downloaded interconnected text application would be considered to have “control” over the transmission of text messages for the purposes of any requirements we adopt.

If a user or third party modifies or manipulates the application after it is installed or downloaded so that it no longer supports bounce-back messaging, should the application provider be presumed not to have control?. 50. If we adopt a bounce-back requirement, should we specify or provide guidance regarding the content of the bounce-back message, and if so, what should we specify or encourage?. Similar to automatic messages sent in response to undeliverable texts to 911, we propose that any bounce-back messages to consumers attempting to text 988 would not require all covered text providers to use identical wording for their automatic responses.

Rather, if we were to adopt a bounce-back requirement, we propose that a covered text provider would be deemed to have met its obligation so long as the bounce-back message to 988 includes, at a minimum, two essential points of information. (1) That text-to-988 is not available. And (2) identify other means to reach the Lifeline, such as by telephone. We seek comment on this approach and on alternatives.

We seek comment on what role our federal partners and non-governmental mental health organizations could play in developing best practices regarding the content of messages. 7. Role of the Substance Abuse and Mental Health Services Administration and the Department of Veterans Affairs 51. Although the Commission has an important role to play in expanding access to crisis counseling through its implementation of 988, SAMHSA and the VA are ultimately responsible for ensuring the continued success of these lifesaving resources.

As such, we propose to direct the Bureau to continue to coordinate the implementation of 988 with SAMHSA and the VA, including any issues pertaining to the delivery of text messages to 988. 52. We seek comment on this proposal. How we can best support the work of our federal partners in administering the Lifeline and Veterans Crisis Line?.

We recognize that many commenters have stressed the importance of ensuring adequate funding and staffing for the Lifeline and the Veterans Crisis Line over the course of this proceeding. Although these issues are beyond our jurisdiction, are there unique considerations pertaining to staffing, funding, or the availability of other resources at the Lifeline or Veterans Crisis Line that we should be aware of as we consider adopting rules to require the delivery of text messages to 988?. How should we account for the possibility that text-to-988 may be popular and increase demands on the Lifeline and Veterans Crisis Line?. What resources will be needed for the Lifeline and Veterans Crisis Line to ensure that text-to-988 is a success?.

How should we account for our federal partners' budget cycles?. We are cognizant of the potential burdens our proposals may impose upon our federal partners, Start Printed Page 31413including personnel, equipment, and resource allocation, and we seek comment on the impact the possible implementation solutions may have on SAMHSA and the VA when supporting text-to-988 service. To that end, we intend to coordinate with SAMHSA and the VA, and we encourage other industry stakeholders in the wireless and texting service industry to coordinate with these agencies as well. Assuming that our adoption of rules implementing text-to-988 capability will require expenditure of additional resources by SAMHSA and the VA, are there ways that we can structure our rules to minimize the burden on our federal partners?.

Are there any steps we should take to deter misuse of text-to-988, so as to limit the unnecessary expenditure of resources by our federal partners?. Are there any solutions that have been employed in other contexts, such as text-to-911, that we or others should adapt here to deter misuse of text-to-988?. 53. In addition, we encourage SAMHSA and the VA to coordinate with outside organizations that have expertise in providing crisis counseling via text message as they develop the infrastructure to receive and respond to text messages which may one day be delivered to the Lifeline and Veterans Crisis Line via 988.

Many commenters in this proceeding have urged collaboration between private entities like the Trevor Project and federal agencies providing similar services. We therefore seek comment on how to facilitate such coordination across federal agencies and the private sector, as we work towards our shared goal of ensuring that all Americans have ready access to mental health counseling and support services. C. Legal Authority 54.

We propose concluding that we have the authority to adopt the rules proposed and for which we seek comment in this further notice of proposed rulemaking under Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA). We seek comment on these and any other sources of authority available to us. In particular, we seek comment on whether, and if so, to what extent, our numbering authority under section 251(e) of the Act provides an additional source of authority for the rules proposed and for which we seek comment in this further notice of proposed rulemaking. Finally, we also seek comment on whether we should employ our ancillary authority.

We note that, in our preliminary review, the National Suicide Hotline Designation Act of 2020 does not provide additional support for—nor does it hinder—the actions proposed in this further notice of proposed rulemaking. We seek comment on these views. 55. The rules we propose and for which we seek comment in this further notice of proposed rulemaking are analogous to those the Commission has adopted to facilitate text-to-911 communications, which relied, in part, on the Commission's Title III authority over wireless carriers, including sections 301, 303, 307, 309, and 316.

We propose concluding that, with respect to CMRS providers, Title III provides us with appropriate authority to require wireless carriers to support text-to-988 service and to require delivery of a bounce-back message to consumers in cases where delivery of a text to 988 cannot be completed. As the Supreme Court has long recognized, Title III grants the Commission a “comprehensive mandate” regarding regulation of spectrum usage, and courts have routinely found that Title III provides the Commission with “broad authority to manage spectrum. . .

In the public interest.” As we explain, we believe the rules we propose in this further notice of proposed rulemaking are likely to have significant public interest benefits. And, the Commission has previously found that its Title III licensing authority supported adoption of a similar set of obligations in the text-to-911 context. Therefore, we believe that with respect to CMRS providers, Title III provides sufficient authority here. We note that, following the release of the Text-to-911 Order, the Commission released a Declaratory Ruling classifying SMS and MMS services as “information services” under the Act.

However, as the Commission explicitly noted in the Declaratory Ruling, this determination “does not affect the general applicability of the spectrum allocation and licensing provisions of Title III and the Commission's rules” to SMS and MMS services, nor does it affect the specific application of sections 301, 303, 307, 309, and 316 to the Commission's text-to-911 rules. We seek comment on this analysis. 56. With respect to interconnected text messaging service providers, we propose to find that the CVAA provides us with authority to adopt the proposals in this further notice of proposed rulemaking, as some commenters in this proceeding suggest.

Congress enacted the CVAA to increase the accessibility of modern communications technologies to people with disabilities, including access related to emergency services, and the Commission relied, in part, on this authority when it adopted similar text-to-911 requirements. The CVAA provides the Commission with authority to “achiev[e] equal access to emergency services by individuals with disabilities, as a part of the migration to a national internet protocol-enabled emergency network.” In particular, the CVAA granted the Commission the authority to adopt regulations to implement recommendations proposed by the Emergency Access Advisory Committee established by the CVAA, which concern access to 911 and NG911 services, and to adopt “other regulations” as are necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network. We tentatively conclude that the CVAA provides authority for our proposals because access to 988 is similar to 911 access for the purposes of our CVAA authority. We seek comment on this tentative conclusion.

Do commenters agree that access to the Lifeline or Veterans Crisis Line through 988 constitute “access to emergency services” under the CVAA?. Do commenters agree that text-to-988 is necessary to achieve reliable, interoperable communication that ensures access by persons with disabilities to an IP-enabled emergency services network?. More generally, does the CVAA provide us with authority to adopt the rules proposed in this further notice of proposed rulemaking?. 57.

We seek comment on any other sources of authority available to the Commission to adopt the proposals detailed in this further notice of proposed rulemaking. In particular, we seek comment on whether our section 251(e) authority over numbering provides authority to require support for text-to-988 service. Section 251(e)(1) of the Act grants us “exclusive jurisdiction over those portions of the North American Numbering Plan that pertain to the United States” and provides that numbers must be made “available on an equitable basis.” This provision gives the Commission “authority to set policy with respect to all facets of numbering administration in the United States.” The Commission found in the 988 Report and Order that section 251(e) provides us with the ability to regulate interconnected and one-way VoIP providers that make use of numbering resources when they connect with the PSTN. We seek comment on whether our numbering authority provides an additional, independent basis to adopt rules with respect to CMRS providers Start Printed Page 31414and interconnected text messaging services.

58. We also seek comment on the Commission's authority to mandate location information with text-to-988 service. Section 222 of the Communications Act, as amended, provides strong legal protections for customer proprietary network information (CPNI), including geolocation information. Section 222(d) provides exceptions to allow CPNI and call location data to be shared for “emergency services.” We seek comment on whether this could encompass the transmission of geolocation information with 988 calls.

Should we choose to require covered text providers to include location information with texts to 988, does section 222 authorize the disclosure of location information with texts to 988?. Are there other privacy concerns that we should consider with regard to texts to 988?. 59. Finally, we seek comment on whether exercise of our ancillary authority would be necessary or appropriate to support any of our proposed rules.

The Commission relied in part on ancillary authority to apply the bounce-back notification requirement to providers of interconnected text messaging services when it adopted text-to-911 requirements. Would a similar finding be appropriate with respect to any aspect of our text-to-988 rules?. D. Benefits and Costs of Text-to-988 60.

We expect to find that the benefits of requiring service providers to support text-to-988 service will exceed the costs of implementation. We seek comment on this proposal, and any specific data regarding both the benefits of facilitating access to the Lifeline via texts to 988 and on the costs or burdens implementation of text-to-988 may impose upon covered text providers. 61. Suicide causes shock, anguish, grief, and guilt among victims' families and friends.

Suicide attempts exact a similarly heavy toll on the community and the victim. The long-lasting damage from mental distress and suicide can extend deep into communities. As outlined above, we preliminarily believe that enabling text-to-988 service will improve access to lifesaving resources for individuals contemplating suicide or experiencing mental health crises, especially for members of at-risk communities such as young people, LGBTQ, people of color, and individuals with disabilities, thereby saving lives. By expanding access to counseling, text-to-988 may help break the cycle of pain, suffering, and suicide.

We seek comment generally on these and other important benefits that may follow from increased access to mental health resources via texting to 988. 62. We further seek comment on ways to quantify these benefits. Of course, the benefits to individuals who the Lifeline or Veterans Crisis Line places on a path to recovery, much less to their families and friends, cannot be reduced to dollars and cents.

That being said, even if text-to-988 service could annually place just one-per-one-thousand suicide victims on a path to long-term recovery, the economic gain would be $19.2 million in any single year, for a present-value of $78.7 million over five years and $134.9 million over ten years. In estimating benefits, we focus on teens and individuals with disabilities, as individuals in these groups are more likely to use a text-to-988 capability. Based on the most recent CDC data from 2015-2019, 11,283 youth (ages 15-19) and an estimated 13,101 individuals who are deaf, hard of hearing, deafblind or speech disabled committed suicide (using an estimated incidence among adults of 6%), or an average of more than 2,000 per year for each group. To calculate the estimated benefits for a single year, we multiply the annual average by 0.1% and the VSL (2,000 * 0.001 * $9.6 million = $19.2 million).

We discount over five years and ten years at a 7% discount rate. We seek comment on this analysis. 63. Our proposed analysis does not examine certain categories of benefits.

For example, we have not estimated the cost savings from medical expenses and loss-of-work avoided through reduced suicides and suicide attempts. We also have not estimated the cost savings of reduced burdens on PSAPs, police, ambulance, and fire and rescue services, which currently respond to some 911 texts that will be routed to the Lifeline, where they will be more effectively and efficiently de-escalated or otherwise resolved. Moreover, we have not examined the benefits of text-to-988 usage by every demographic group. For example, smartphone ownership and suicide are particularly common in younger age groups.

According to the Common Sense Census. Media Use by Tweens and Teens, 2019, 53% of children have their own smartphone by age 11, and 69% have one at age 12. Currently, our estimated benefits analysis looks at youth ages 15-19. To accurately estimate these benefits, we seek comment on how broadly we should define youth who may text to 988.

Relatedly, there is the possibility that adults without hearing or speech disabilities may rely exclusively on text-to-988 for added privacy or convenience, meriting inclusion in our benefit estimates. We also seek comment on ways to better assess the long-term impact of text-to-988 service. Without longitudinal studies evaluating the long-term effectiveness of suicide call centers, we cannot pinpoint how many suicides text-to-988 will prevent in the long run. Available survey-based studies, however, reveal call centers can substantially reduce suicides during the initial call and follow-up periods.

We seek comment on the types and magnitudes of these and other benefits not covered in this further notice of proposed rulemaking, as well as any overlooked categories of costs. 64. In the Text-to-911 proceeding, the Commission estimated that the total cost for covered providers to implement text-to-911 service amounted to less than $21 million. The costs of nationwide deployment of text-to-911 fell into three categories.

CMRS and PSAP system cost components. Interconnected text providers' software upgrades. And bounce-back messaging application alterations and server platform modifications. Assuming that all or most of the software and equipment necessary to receive and transmit 911 texts will again be needed to deploy text-to-988, we expect that the implementation costs for text-to-988 service will be comparable to the costs for text-to-911 service.

Using cost estimates from the Text-to-911 proceeding as a model, we estimate it will cost $19,024,916 for CMRS providers to implement text-to-988, $613,275 for interconnected text messaging service providers to implement text-to-988, and $7,310,340 for Lifeline to route texts to local crisis centers. We convert the estimate for CMRS providers to implement text-to-911 service to 2021 dollars by multiplying by a Consumer Price Index (CPI) factor of 1.16, then discounting over five years at a 7% discount rate. Similarly, we convert the estimate for interconnected text messaging providers to implement text-to-911 service into 2021 dollars by using a CPI factor of 1.105. To soberly assess Lifeline capability, we assume that 100% of Lifeline call centers may require SMS upgrades and thus multiply PSAP software estimates by 2.22.

To estimate the costs to equip the more than 180 Lifeline crisis centers, we calculate an average cost based on an estimated per PSAP cost of $40,613 (=($263,277,595 + $12,891,283)/6,800), for a total of $7,310,340 (=180 * $40,613). Therefore, we preliminarily estimate that total costs for implementing text-to-988 will be approximately $27 million. We seek Start Printed Page 31415comment on this analysis, including our preliminary assumption that text-to-911 software and equipment can be leveraged for texting to 988. Do commenters agree with CTIA that there are “significant technical and policy differences” between 988 and 911 service, and if so, how might those differences impact our evaluation?.

Furthermore, we seek comment on whether cost estimates for PSAPs from the Text-to-911 proceeding reflect an appropriate estimate for costs to the Lifeline or Veterans Crisis Line. Are there other costs borne by the Lifeline or Veterans Crisis Line needed to implement text-to-988 service?. 65. We preliminarily assume that some costs may be streamlined or reduced due to the previous implementation of text-to-911, which may be leveraged to facilitate text-to-988 capability and seek comment on this assumption.

As a result, we anticipate that costs for covered text providers to implement text-to-988 may be less than what we estimate above and seek comment on this finding. We further seek comment on what extent covered text providers may rely upon existing text-to-911 services and how to quantify the costs needed to upgrade such systems to support text-to-988. 66. Deterring suicide has benefits that simply cannot be reduced to numbers—saving lives has value beyond measure.

While recognizing this fact, to illustrate how the benefits of our proposal relate to the more aptly quantified costs, we attempt to estimate the quantifiable value of suicide prevention using a measure of collective willingness to pay. We propose calculating that the level of suicide prevention needed to generate benefits exceeding our preliminary estimate of $27 million in text-to-988 costs is a total of four suicides avoided over five years. Specifically, the level of teen suicide prevention needed to generate benefits exceeding $27 million is one per 2,821, and the level of suicide prevention among individuals with disabilities to generate benefits exceeding $27 million is one per 3,275. Even assuming that text-to-988 prevented no suicides in its inaugural year as the service rolled out but prevented one suicide in each of the ensuing four years, measured in terms of the public's willingness to pay for that mortality reduction, the present value of the benefit would be $30.39 million, more than three million dollars greater than the total cost.

The present value would be an uneven stream of payments of $9.6 million ($0 in Year 1 + $9.6 million per year in Year 2 through Year 5) at a 7% discount rate. We seek comment on our analysis. 67. Using break-even points and highly attainable suicide reductions that are well below those suggested by survey studies, we estimate that the benefits of text-to-988 will far exceed the costs.

Pooling teenagers and individuals with disabilities, we estimate that text-to-988 would need to prevent one suicide out of every six thousand in order to break-even in the first five years of deployment. Slightly raising the bar to preventing one suicide per one thousand, we further estimate that the more than $157.5 million estimated benefit from modestly reducing suicides in two vulnerable populations far exceeds the text-to-988 deployment costs of $19.6 million incurred by CMRS and interconnected text providers. Even if sizable Lifeline deployment costs are added, increasing estimated total cost to nearly $27 million, the estimated benefits of text-to-988 remain greater by a multiple of nearly six. Over ten years, the benefits rise to $269.8 million, exceeding costs by a multiple of nearly ten.

We seek comment on these estimates. We also seek comment on the methods and underlying benefits and costs estimates, including those submitted by third parties, used to arrive at our overall proposed conclusion. II. Initial Regulatory Flexibility Analysis 1.

As required by the Regulatory Flexibility Act of 1980, as amended (RFA), the Commission has prepared this Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities by the policies and rules proposed in this Implementation of the National Suicide Hotline Improvement Act of 2018 further notice of proposed rulemaking (FNPRM). The Commission requests written public comments on this IRFA. Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments provided on the first page of the further notice of proposed rulemaking. The Commission will send a copy of the further notice of proposed rulemaking, including this IRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA).

In addition, the further notice of proposed rulemaking and IRFA (or summaries thereof) will be published in the Federal Register. A. Need for, and Objectives of, the Proposed Rules 2. In this FNPRM, the Commission proposes and seeks comment on requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, the PSTN (covered text providers) to enable delivery of text messages to 988.

The Commission proposes to require that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK). The Commission believes these proposed rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988. B. Legal Basis 3.

The legal basis for any action that may be taken pursuant to this FNPRM is contained in sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251, 301, 303, 307, 309, 316. C. Description and Estimate of the Number of Small Entities to Which the Proposed Rules Will Apply 4.

The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the proposed rules and by the rule revisions on which the Notice seeks comment, if adopted. The RFA generally defines the term “small entity” as having the same meaning as the terms “small business,” “small organization,” and “small governmental jurisdiction.” In addition, the term “small business” has the same meaning as the term “small-business concern” under the Small Business Act. A “small-business concern” is one which. (1) Is independently owned and operated.

(2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA. 5. Small Businesses, Small Organizations, Small Governmental Jurisdictions.

Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein. First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the Small Business Administration's (SBA) Office of Advocacy, in general a small business is an independent business having fewer than 500 employees. These types of small businesses represent 99.9% of all businesses in the United Start Printed Page 31416States, which translates to 30.7 million businesses.

6. Next, the type of small entity described as a “small organization” is generally “any not-for-profit enterprise which is independently owned and operated and is not dominant in its field.” The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations. Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S. Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS.

7. Finally, the small entity described as a “small governmental jurisdiction” is defined generally as “governments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.” U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose governments and special purpose governments in the United States. Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governments—independent school districts with enrollment populations of less than 50,000.

Accordingly, based on the 2017 U.S. Census of Governments data, we estimate that at least 48,971 entities fall into the category of “small governmental jurisdictions.” 8. Wired Telecommunications Carriers. The U.S.

Census Bureau defines this industry as “establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies. Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.” The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small.

9. Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable NAICS Code category is Wired Telecommunications Carriers.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees.

Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 10. Incumbent LECs. Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services.

The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated the entire year.

Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, the Commission estimates that most providers of incumbent local exchange service are small businesses that may be affected by our actions. According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees.

Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities. 11. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers.

Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities. According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services. Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees.

In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

12. We have included small incumbent LECs in this present RFA analysis. As noted above, a “small business” under the RFA is one that, inter alia, meets the pertinent small business size standard (e.g., a telephone communications business having 1,500 or fewer employees), and “is not dominant in its field of operation.” The SBA's Office of Advocacy contends that, for RFA purposes, small incumbent LECs are not dominant in their field of operation because any such dominance is not “national” in scope. We have therefore included small incumbent LECs in this RFA analysis, although we emphasize that this RFA action has no effect on Commission analyses and determinations in other, non-RFA contexts.

13. Interexchange Carriers (IXCs). Neither the Commission nor the SBA has developed a small business size standard specifically for Interexchange Carriers. The closest applicable NAICS Code category is Wired Telecommunications Carriers.

The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees.

According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees. Start Printed Page 31417Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 14.

Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers. The SBA category of Telecommunications Resellers is the closest NAICs code category for local resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year. Of that number, all operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities.

According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services. Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees. Consequently, the Commission estimates that the majority of local resellers are small entities. 15.

Toll Resellers. The Commission has not developed a definition for Toll Resellers. The closest NAICS Code Category is Telecommunications Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry. The SBA has developed a small business size standard for the category of Telecommunications Resellers.

Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S. Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services. Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities.

16. Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers.

The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage. Of these, an estimated 279 have 1,500 or fewer employees.

Consequently, the Commission estimates that most Other Toll Carriers are small entities. 17. Prepaid Calling Card Providers. Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers.

The most appropriate NAICS code-based category for defining prepaid calling card providers is Telecommunications Resellers. This industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure.

Mobile virtual networks operators (MVNOs) are included in this industry. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year.

Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities. According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities.

18. Wireless Telecommunications Carriers (except Satellite). Neither the SBA nor the Commission has developed a size standard specifically applicable to Wireless Carriers and Service Providers. The closest applicable is Wireless Telecommunications Carriers (except Satellite), which the SBA small business size standard is such a business is small if it 1,500 persons or less.

For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms had employment of 999 or fewer employees and 12 had employment of 1000 employees or more. Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Carriers and Service Providers are small entities.

19. According to internally developed Commission data for all classes of Wireless Service Providers, there are 970 carriers that reported they were engaged in the provision of wireless services. Of this total, an estimated 815 have 1,500 or fewer employees, and 155 have more than 1,500 employees. Thus, using available data, we estimate that the majority of Wireless Carriers and Service Providers can be considered small.

20. Cable and Other Subscription Programming. The U.S. Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis.

The broadcast programming is typically narrowcast in nature (e.g., limited format, such as news, sports, education, or youth-oriented). These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite Start Printed Page 31418systems, for transmission to viewers.” The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million. Based on U.S.

Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small. 21.

Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation. Under the Commission's rules, a “small cable company” is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States.

Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard. In addition, under the Commission's rate regulation rules, a “small system” is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have 15,000 or more subscribers, based on the same records.

Thus, under this standard as well, we estimate that most cable systems are small entities. 22. Cable System Operators (Telecom Act Standard). The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is “a cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.” As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States.

Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard. We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million. Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act.

23. All Other Telecommunications. The “All Other Telecommunications” category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Establishments providing internet services or voice over internet protocol (VoIP) services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for “All Other Telecommunications”, which consists of all such firms with annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year.

Of those firms, a total of 1,400 had annual receipts less than $25 million and 15 firms had annual receipts of $25 million to $49,999,999. Thus, the Commission estimates that the majority of “All Other Telecommunications” firms potentially affected by our action can be considered small. 24. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing.

This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are. Transmitting and receiving antennas, cable television equipment, GPS equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 or fewer employees.

U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees. Based on this data, we conclude that a majority of manufacturers in this industry are small.

25. Semiconductor and Related Device Manufacturing. This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices.

The SBA has developed a small business size standard for Semiconductor and Related Device Manufacturing, which consists of all such companies having 1,250 or fewer employees. U.S. Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees.

Thus, under this size standard, the majority of firms in this industry can be considered small. 26. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction.

Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only. The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S.

Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small. 27.

Internet Service Providers (Broadband). Broadband internet service providers include wired (e.g., cable, DSL) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies.

The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated Start Printed Page 31419that year. Of this total, 3,083 operated with fewer than 1,000 employees.

Consequently, under this size standard the majority of firms in this industry can be considered small. 28. Internet Service Providers (Non-Broadband). Internet access service providers such as Dial-up internet service providers, VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections (e.g., dial-up ISPs) fall in the category of All Other Telecommunications.

The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million.

Consequently, under this size standard a majority of firms in this industry can be considered small. 29. All Other Information Services. The U.S.

Census Bureau has determined that this category “comprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and broadcasting, and Web search portals).” The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less. U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49, 999,999.

Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. D. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 30. The FNPRM proposes and seeks comment on rules to require covered text providers to support text messaging to 988.

It tentatively concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations, and thereby save lives. The proposed rules would require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK). The FNPRM proposes (1) establishing a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. And (2) directing the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number.

The FNPRM seeks comment on this proposal. The Commission preliminarily believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules for different covered text providers. The Commission proposes that the costs and/or administrative burdens associated with the rules will not unduly burden small entities. E.

Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 31. The RFA requires an agency to describe any significant alternatives that it has considered in reaching its proposed approach, which may include the following four alternatives (among others). (1) The establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities.

(3) the use of performance rather than design standards. And (4) an exemption from coverage of the rule, or any part thereof, for such small entities. 32. In the FNPRM, the Commission seeks comment from all entities, including small entities, regarding the impact of these proposed rules on small entities.

The Commission seeks comment on the impact, cost or otherwise, that requiring text messaging to 988 capability will impose on regional and rural carriers and small businesses. The Commission also seeks comment on whether to adopt any exemptions for small businesses and if so, under what circumstances. The Commission asks and will consider alternatives to the proposals and on alternative ways of implementing the proposals. F.

Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 33. None. III. Procedural Matters 34.

Ex Parte Rules. This proceeding shall be treated as a “permit-but-disclose” proceeding in accordance with the Commission's ex parte rules. Persons making ex parte presentations must file a copy of any written presentation or a memorandum summarizing any oral presentation within two business days after the presentation (unless a different deadline applicable to the Sunshine period applies). Persons making oral ex parte presentations are reminded that memoranda summarizing the presentation must (1) list all persons attending or otherwise participating in the meeting at which the ex parte presentation was made, and (2) summarize all data presented and arguments made during the presentation.

If the presentation consisted in whole or in part of the presentation of data or arguments already reflected in the presenter's written comments, memoranda or other filings in the proceeding, the presenter may provide citations to such data or arguments in his or her prior comments, memoranda, or other filings (specifying the relevant page and/or paragraph numbers where such data or arguments can be found) in lieu of summarizing them in the memorandum. Documents shown or given to Commission staff during ex parte meetings are deemed to be written ex parte presentations and must be filed consistent with Rule 1.1206(b). In proceedings governed by Rule 1.49(f) or for which the Commission has made available a method of electronic filing, written ex parte presentations and memoranda summarizing oral ex parte presentations, and all attachments thereto, must be filed through the electronic comment filing system available for that proceeding, and must be filed in their native format (e.g., .doc, .xml, .ppt, searchable .pdf). Participants in this proceeding should familiarize themselves with the Commission's ex parte rules.

35. Initial Regulatory Flexibility Analysis. Pursuant to the Regulatory Flexibility Act (RFA), the Commission has prepared an Initial Regulatory Flexibility Analysis (IRFA) of the possible significant economic impact on small entities of the policies and actions considered in this FNPRM. Written public comments are requested on this IRFA.

Comments must be identified as responses to the IRFA and must be filed by the deadlines for comments on the FNPRM. The Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, will send a copy of the FNPRM, including the IRFA, to the Chief Counsel for Advocacy of the Small Business Administration.Start Printed Page 31420 36. Comment Filing Procedures. Pursuant to §§ 1.415 and 1.419 of the Commission's rules, 47 CFR 1.415, 1.419, interested parties may file comments and reply comments on or before the dates indicated on the first page of this document.

Comments may be filed using the Commission's Electronic Comment Filing System (ECFS). See Electronic Filing of Documents in Rulemaking Proceedings, 63 FR 24121 (1998). Electronic Filers. Comments may be filed electronically using the internet by accessing ECFS.

Https://www.fcc.gov/​ecfs/​. Paper Filers. Parties who choose to file by paper must file an original and one copy of each filing. Filings can be sent by commercial overnight courier, or by first-class or overnight U.S.

Postal Service mail. All filings must be addressed to the Commission's Secretary, Office of the Secretary, Federal Communications Commission. Commercial overnight mail (other than U.S. Postal Service Express Mail and Priority Mail) must be sent to 9050 Junction Drive, Annapolis Junction, MD 20701.

U.S. Postal Service first-class, Express, and Priority mail must be addressed to 45 L Street NE, Washington, DC 20554. Effective March 19, 2020, and until further notice, the Commission no longer accepts any hand or messenger delivered filings. This is a temporary measure taken to help protect the health and safety of individuals, and to mitigate the transmission of anti inflammatory drugs.

See FCC Announces Closure of FCC Headquarters Open Window and Change in Hand-Delivery Policy, Public Notice, 35 FCC Rcd 2788 (OS 2020), https://www.fcc.gov/​document/​fcc-closes-headquarters-open-window-and-changes-hand-delivery-policy. 37. People with Disabilities. To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &.

Governmental Affairs Bureau at (202) 418-0530 (voice). 38. Paperwork Reduction Act of 1995 Analysis. This document may contain proposed new or modified information collection requirements.

The Commission, as part of its continuing effort to reduce paperwork burdens, invites the general public and the Office of Management and Budget (OMB) to comment on the information collection requirements contained in this document, as required by the Paperwork Reduction Act of 1995, Public Law 104-13. In addition, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, we seek specific comment on how we might further reduce the information collection burden for small business concerns with fewer than 25 employees. 39. Contact Person.

For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV. Ordering Clauses 40. It is ordered, pursuant to sections 201, 251, 301, 303, 307, 309, and 316 of the Communications Act of 1934, as amended, 47 U.S.C.

201, 251, 301, 303, 307, 309, 316, that the FNPRM in WC Docket No. 18-336 is adopted. 41. It is further ordered that the Petition for Reconsideration filed by Communications Equality Advocates is granted in part to the extent described herein.

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Studying how a http://sjgroup.co.uk/buy-antabuse-online-canada/ community symbicort price canada relates to the passage of time, I’ve learned, can offer a window into its values, worldviews, and lifeways. From 2012 to 2014, I conducted 32 months of anthropological fieldwork exploring how Finland’s nuclear energy waste experts grappled with Earth’s radically long-term future. These experts routinely dealt with long-lived radionuclides such as uranium-235, which has a half-life of over 700 million years.

They worked with the nuclear waste management symbicort price canada company Posiva to help build a final disposal facility approximately 450 meters below the islet of Olkiluoto in the Gulf of Bothnia in the Baltic Sea. If all goes according to plan, this facility will, in the mid-2020s, become the world’s first operating deep geologic repository for spent nuclear fuel. To assess the Olkiluoto repository’s long-term durability, these experts developed a “safety case” forecasting geological, hydrological, and ecological events that could potentially occur in Western Finland over the coming tens of thousands—or even hundreds of thousands—of years.

From their efforts emerged visions of distant future glaciations, climate changes, symbicort price canada earthquakes, floods, human and animal population changes, and more. These forecasts became the starting point for a series of “mental time travel” exercises that I incorporated into my book, Deep Time Reckoning. Stretching the mind across time—even in the most speculative ways—can help us become more responsible planetary stewards.

It can help endow us with the time literacy necessary for tackling long-term challenges such as symbicort price canada biodiversity loss, microplastics accumulation, climate change, antibiotic resistance, asteroid impacts, sustainable urban planning, and more. This can not only make us feel more at home in pondering our planet’s pasts and futures. It can also draw us to imagine the world from the perspective of future human and non-human communities—fostering empathy across generations.

The year symbicort price canada 5710 CE. A tired man lounges on a sofa. He lives in a small wooden house in a region once called Eurajoki, Finland.

He works at a local symbicort price canada medical center. Today is his day off. He’s had a long day in the forest.

He hunted moose and deer and picked lingonberries, symbicort price canada mushrooms, and bilberries. He now sips water, drawn from a village well, from a wooden cup. His husband brings him a dinner plate.

On it are fried potatoes, cereal, symbicort price canada boiled peas, and beef. All the food came from local farms. The cattle were watered at a nearby river.

The crops symbicort price canada were watered by irrigation channels flowing from three local lakes. The man has no idea that, more than 3,700 years ago, safety case biosphere modelers used 21st-century computer technologies to reckon everyday situations like his. He does not know that they once named the lakes around him—which formed long after their own deaths—“Liiklanjärvi,” “Tankarienjärvi,” and “Mäntykarinjärvi.” He is unaware of Posiva’s ancient determination that technological innovation and cultural habits are nearly impossible to predict even decades in advance.

He is unaware that Posiva, in response, instructed its modelers to pragmatically assume that Western Finland’s populations’ lifestyles, demographic symbicort price canada patterns, and nutritional needs will not change much over the next 10,000 years. He does not know the safety case experts inserted, into their models’ own parameters, the assumption that he and his neighbors would eat only local food. Yet the hunter’s life is still entangled with the safety case experts’ work.

If they had symbicort price canada been successful, then the vegetables, meat, fruit, and water before him should have just a tiny chance of containing only tiny traces of radionuclides from 20th-century nuclear power plants. 12020 CE. A solitary farmer looks out over her pasture, surrounded by a green forest of heath trees.

She lives in a sparse land once called Finland, symbicort price canada on a fertile island plot once called Olkiluoto. The area is an island no longer. What was once a coastal bay is now dotted with small lakes, peat bogs, and mires with white sphagnum mosses and grassy sedge plants.

The Eurajoki symbicort price canada and Lapijoki Rivers drain out into the sea. When the farmer goes fishing at the lake nearby, she catches pike. She watches a beaver swim about.

Sometimes she feels symbicort price canada somber. She recalls the freshwater ringed seals that once shared her country before their extinction. The woman has no idea that, deep beneath her feet, lies an ancestral deposit of copper, iron, clay, and radioactive debris.

This is a highly classified symbicort price canada secret—leaked to the public several times over the millennia, but now forgotten. Yet even the government’s knowledge of the burial site is poor. Most records were destroyed in a global war in the year 3112.

It was then that ancient forecasts of the site, found in the 2012 safety case report “Complementary symbicort price canada Considerations,” were lost to history. But the farmer does know the mythical stories of Lohikäärme. A dangerous, flying, salmon-colored venomous snake that kills anyone who dares dig too close to his underground cave.

She and the other farmers in the area grow crops symbicort price canada of peas, sugar beet, and wheat. They balk at the superstitious fools who tell them the monster living beneath their feet is real. 35,012 CE.

A tiny microbe floats in a large, northern symbicort price canada lake. It does not know that the clay, silt, and mud floor below it is gaining elevation, little by little, year after year. It is unaware that, 30 millennia ago, the lake was a vast sea.

Dotted with sailboats, cruise and cargo ships, it symbicort price canada was known by humans as the Baltic. Watery straits, which connected the Baltic Sea to the North Sea, had risen above the water thousands of years ago. Denmark and Sweden fused into a single landmass.

The seafloor symbicort price canada was decompressing from the Weichselian glaciation—an enormous sheet of ice that pressed down on the land during a previous ice age. After the last human died, the landmass kept on rising. Its uplift was indifferent to human extinction.

It was indifferent to how, in 2013 CE, an anthropologist and a safety case symbicort price canada expert sat chatting in white chairs in Ravintola Rytmi. A café in Helsinki. There, the safety case expert relayed his projection that, by 52,000 CE, there would no longer be water separating Turku, Finland, and Stockholm, Sweden.

At that point, one could walk from one symbicort price canada city to the other on foot. The expert reckoned that, to the north—between Vaasa, Finland, and Umeå, Sweden—one would someday find a waterfall with the planet’s largest deluge of flowing water. The waterfall could be found at the site of a once-submerged sea shelf.

The microbe, though, does not know or care about Vaasa, Umeå, Denmark, long-lost boats, safety case symbicort price canada reports, or Helsinki’s past dining options. It has no concept of them. Their significances died with the humans.

Nor does the microbe grasp the suffering they faced when symbicort price canada succumbing to Anthropocene collapse. Humans’ past technological feats, grand civilizations, passion projects, intellectual triumphs, wartime sacrifices, and personal struggles are now moot. And yet, the radiological safety of the microbe’s lake’s waters still hinges on the work of a handful of human safety case experts who lived millennia ago.

Thinking so far ahead, symbicort price canada these experts never lived to see whether their deep time forecasts were accurate. We do not, of course, live in these imagined worlds. In this sense, they are unreal—merely fictions.

However, our capacities to envision potential futures, and to feel empathy for symbicort price canada those who may inhabit them, are very real. Depictions of tomorrow can have powerful, concrete effects on the world today. This is why deep time thought experiments are not playful games, but serious acts of intellectual problem-solving.

It is why the safety case experts’ symbicort price canada models of far future nuclear waste risks are uniquely valuable, even if they are, at the end of the day, mere approximations. Yet pondering distant future Earths can also help us take a step back from our everyday lives—enriching our imaginations by transporting our minds to different places and times. Corporate coaches have recommended taking breaks from our familiar thinking patterns to experience the world in new ways and overcome mental blocks.

Cognitive scientists have shown how creativity can be sparked by perceiving "something one has not seen before (but that was probably always there).” Putting aside a few symbicort price canada minutes each day for long-termist, planetary imagination can enrich us with greater mental dexterity in navigating between multiple, interacting timescales. This can cultivate more longsighted empathy for landscapes, people, and other organisms across decades, centuries, and millennia. As the global ecological crisis takes hold, embracing planetary empathy will prove essential to our collective survival.

This is an opinion symbicort price canada and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American. This essay first appeared in the MIT Reader on August 10, 2021.Beginning in May and appearing to slow down by the end of July, juvenile songbirds from the mid-Atlantic to the Midwest fell ill with odd symptoms and died.

Scientists were baffled symbicort price canada by the mass mortality event. Months later they still do not know what killed the birds. Suspects include pathogens that the victims could have contracted by consuming Brood X cicadas and environmental toxins to which the young birds were particularly vulnerable.

Brian Evans, an ornithologist symbicort price canada at the Smithsonian National Zoo and Conservation Biology Institute in Washington, D.C., is part of a collaborative effort that draws on community science to find out more about the scope of the event and narrow down the possible causes.* Scientific American spoke with Evans about the efforts to solve this ongoing mystery, the impact of community scientists and what the public can do to help. [An edited transcript of the interview follows.] When did you first learn about these songbirds dying?. It first came to my attention in early to mid-May.

Early on, I symbicort price canada didn’t believe it. I know that fledgling mortality rates are phenomenally high in general. So to hear word of a bunch of people observing a lot of dead and dying fledglings, as an ornithologist, frankly, didn’t come as much surprise.

I had about five birds at that point in my backyard that had symbicort price canada basically fallen out of the sky, and I blamed crows because I have an incredible crow population in my neighborhood [in Takoma Park, Md.]. It wasn’t until late May that my perspective on the event had started to change. One of my neighbors observed a bird on the street, out in front of the yard, that was still alive—all the birds that I had encountered at that point were dead—and described it as having really swollen eyes and this inability to respond to her and just [seeming] generally confused.

Its head symbicort price canada was making tremors. That seemed to me to be an odd set of symptoms to share. We see a lot of swollen eyes in birds, especially house finches and house sparrows, that are infected with a bacterial called Mycoplasma gallisepticum.

But these symptoms that she was symbicort price canada describing didn’t sound like [those] caused by mycoplasma. I went from, at that very moment, being really skeptical to starting to doubt myself. Literally a half an hour later, I received a text message from a field technician at the [Smithsonian] Migratory Bird Center with a picture of an affected bird, and a neighbor called me to tell me that he had a bird that was up the road that was sick.

He and I together went to City Wildlife, which is the rehab agency that has been crucial in getting the word out about the event and connecting various symbicort price canada parties. They let me know when I went there that, from their perspective, this is a serious event and that they are overwhelmed with the number of mortalities that are coming in. What are the symptoms of this condition, and what birds are affected?.

The ophthalmic symptoms can be surprisingly swollen eyes, eyes that jut out of the symbicort price canada head a little bit. They can be crusty eyes. They can be blindness.

The neurological symptoms can be things such as a shaking head, an inability symbicort price canada to stand, involuntary muscle spasms in general. [They] can be depression or lethargy. When you observe one of these birds with this neurological set of symptoms, it’s fairly obvious, because they’re simply unresponsive.

There’s one video that was submitted [via a form that the Smithsonian National Zoo and Conservation Biology Institute set up] of this bird that just had this slow shake to its head and could barely stand and was keeled to the symbicort price canada side. It’s those strange behaviors that I think are most remarkable in this event. To the best of our knowledge, [of those] affected, maybe 90 percent [are] juveniles.

It can be tricky to tell a juvenile from an symbicort price canada adult, but early on, they look really distinct, especially in regard to plumage, and they have a meaty gape around the corners of their mouth when they’re young in June. What did you do once you realized that these were not run-of-the-mill deaths you would expect among juveniles?. The first thing that we did was start to coordinate with City Wildlife, the rehab group.

We’re sending e-mails back and symbicort price canada forth and trying to see. What do we know?. Is this just in [Washington], D.C., or is it in other states?.

How many symbicort price canada birds are affected?. Are we the worst?. We took in specimens that have the neurological/ophthalmic symptoms that are associated with the event, and we’re testing them internally through our Center for Conservation Genomics for everything from viral to bacterial to fungal s.

The other role I’m playing is reaching out to every rehab agency that I can that has specimens of birds that died from other symbicort price canada reasons—so they died because they hit a window or because a cat killed them. Finally, we’re testing truly healthy specimens. We’re going out into the environment, and we’re banding birds and swabbing their eyelids and cloacae.

They’ll act as controls for the conservation genomics group symbicort price canada. It’s all about how ... These specimens that are [symptomatic] differ from other specimens in the environment in terms of their microbial community.

Why has the agent of symbicort price canada disease been so elusive, despite months of this kind of testing?. It’s not just a question of what’s making a given bird sick.... It’s much harder to diagnose a problem that’s shared across a wide geography and a wide timescale and a wide number of species.

What do symbicort price canada all of these specimens have in common that are different from healthy birds?. For example, we know a lot tested positive for mycoplasma [bacteria], but we know that a lot of healthy birds test positive for mycoplasma. And not all the birds that we think are associated with this event tested positive for mycoplasma.

Something could be affecting the birds neurologically that’s also depressing their immune system, that’s allowing a secondary symbicort price canada to come in. What do you think about the hypothesis that the Brood X cicada emergence had something to do with this?. There are a number of hypotheses for what’s potentially driving the event.

Some tests have come back symbicort price canada negative. West Nile symbicort, avian flu, salmonella have come back negative. The cicada hypothesis is actually a set of hypotheses that developed because of really strong overlap between the mortality event and the cicada Brood X distribution.

Areas that symbicort price canada had a lot of cicadas seemed to have a lot of mortalities. Areas with fewer cicadas seemed to have a lower number of mortalities.... We were always careful to say that correlation isn’t causation in this case—we also know that there are a lot more fledglings in the environment in June, at the peak of cicadas, than there would be in July and August.

It’s still a hypothesis that’s on the table, but it’s much less likely now because we’ve symbicort price canada found areas that have been impacted with mortalities that did not have Brood X emerge. It seemed like many of the early reports were from amateur birders and community members, and it took ornithologists a bit of time to take these reports seriously. Does that say anything about professional scientists’ relationship to community science?.

I’m sure it symbicort price canada does. A lot of my research is associated with community science data, but even I share that skepticism toward community science. I think that this was a lesson to me that we’ve got to do a better job as scientists to listen to what the community is saying.

It’s too easy to herald their importance when we agree with what they’re saying or when community scientists are doing symbicort price canada as we would wish them to do. When it’s something like this, when community scientists have observed things prior to us making observations, that’s something else entirely. That’s when the old crotchety scientists in us come in.

What have symbicort price canada you learned from this experience?. I’m frankly a little ashamed that I was such a cocky bastard at the get-go. It was a real lesson in humility for me.

We did this symbicort price canada with anti inflammatory drugs. We too often pretend that something we don’t see isn’t happening. What are the biggest questions about the event that still remain, and do you think we’ll get answers to them?.

I think symbicort price canada it’ll be solved. To me, the biggest thing to solve first is whether it’s caused by an infectious disease or whether it’s caused by a toxin. Everybody’s champing at the bit to put their bird feeders back up.

I’ve heard so much symbicort price canada language and so much pressure—“When can I start feeding birds again?. € And my answer is always “Let’s wait and see what [the U.S. Geological Survey’s National Wildlife Health Center] says.” If it’s an infectious disease, and we care about birds, we shouldn’t be putting our feeders back.

It would also be really important to know if it’s an environmental toxin symbicort price canada. Why did we see it in 2021—in such large numbers?. “Will we see it again in the next breeding season?.

€ is another important question symbicort price canada that lingers. You mentioned guidance from USGS that people in some mid-Atlantic, southeastern and Midwest states should take down their birdfeeders. What else can people do?.

The most important thing that folks can do is just symbicort price canada submit their observations. I’ve gotten reports from people, both through the bird mortality reporting form and from colleagues, in different states that are outside what’s expected to be the affected area. We need to address whether or not our area of impact is, in fact, accurate.

So, for example, if this is occurring in Texas, and Texas does symbicort price canada not have Brood X cicadas, that’s a real problem with the cicada hypothesis. Bird enthusiasts should submit their observations and take a lot of pictures and videos of birds. *Editor’s Note (8/13/21).

Studying how a community relates to can i buy symbicort over the counter the passage of time, I’ve learned, can offer a window into its values, worldviews, and lifeways. From 2012 to 2014, I conducted 32 months of anthropological fieldwork exploring how Finland’s nuclear energy waste experts grappled with Earth’s radically long-term future. These experts routinely dealt with long-lived radionuclides such as uranium-235, which has a half-life of over 700 million years. They worked with the nuclear waste management company Posiva can i buy symbicort over the counter to help build a final disposal facility approximately 450 meters below the islet of Olkiluoto in the Gulf of Bothnia in the Baltic Sea. If all goes according to plan, this facility will, in the mid-2020s, become the world’s first operating deep geologic repository for spent nuclear fuel.

To assess the Olkiluoto repository’s long-term durability, these experts developed a “safety case” forecasting geological, hydrological, and ecological events that could potentially occur in Western Finland over the coming tens of thousands—or even hundreds of thousands—of years. From their can i buy symbicort over the counter efforts emerged visions of distant future glaciations, climate changes, earthquakes, floods, human and animal population changes, and more. These forecasts became the starting point for a series of “mental time travel” exercises that I incorporated into my book, Deep Time Reckoning. Stretching the mind across time—even in the most speculative ways—can help us become more responsible planetary stewards. It can help endow us with the time literacy necessary for tackling long-term challenges such as biodiversity loss, can i buy symbicort over the counter microplastics accumulation, climate change, antibiotic resistance, asteroid impacts, sustainable urban planning, and more.

This can not only make us feel more at home in pondering our planet’s pasts and futures. It can also draw us to imagine the world from the perspective of future human and non-human communities—fostering empathy across generations. The year 5710 can i buy symbicort over the counter CE. A tired man lounges on a sofa. He lives in a small wooden house in a region once called Eurajoki, Finland.

He works at a local medical can i buy symbicort over the counter center. Today is his day off. He’s had a long day in the forest. He hunted moose and deer and picked lingonberries, mushrooms, and can i buy symbicort over the counter bilberries. He now sips water, drawn from a village well, from a wooden cup.

His husband brings him a dinner plate. On it are fried can i buy symbicort over the counter potatoes, cereal, boiled peas, and beef. All the food came from local farms. The cattle were watered at a nearby river. The crops can i buy symbicort over the counter were watered by irrigation channels flowing from three local lakes.

The man has no idea that, more than 3,700 years ago, safety case biosphere modelers used 21st-century computer technologies to reckon everyday situations like his. He does not know that they once named the lakes around him—which formed long after their own deaths—“Liiklanjärvi,” “Tankarienjärvi,” and “Mäntykarinjärvi.” He is unaware of Posiva’s ancient determination that technological innovation and cultural habits are nearly impossible to predict even decades in advance. He is unaware that Posiva, in response, instructed its modelers to pragmatically assume that Western Finland’s populations’ lifestyles, demographic patterns, and can i buy symbicort over the counter nutritional needs will not change much over the next 10,000 years. He does not know the safety case experts inserted, into their models’ own parameters, the assumption that he and his neighbors would eat only local food. Yet the hunter’s life is still entangled with the safety case experts’ work.

If they had been successful, then the vegetables, meat, fruit, and water before him should have just a tiny chance of containing only tiny traces of radionuclides can i buy symbicort over the counter from 20th-century nuclear power plants. 12020 CE. A solitary farmer looks out over her pasture, surrounded by a green forest of heath trees. She lives in a sparse land can i buy symbicort over the counter once called Finland, on a fertile island plot once called Olkiluoto. The area is an island no longer.

What was once a coastal bay is now dotted with small lakes, peat bogs, and mires with white sphagnum mosses and grassy sedge plants. The Eurajoki and can i buy symbicort over the counter Lapijoki Rivers drain out into the sea. When the farmer goes fishing at the lake nearby, she catches pike. She watches a beaver swim about. Sometimes she feels somber can i buy symbicort over the counter.

She recalls the freshwater ringed seals that once shared her country before their extinction. The woman has no idea that, deep beneath her feet, lies an ancestral deposit of copper, iron, clay, and radioactive debris. This is a highly classified secret—leaked can i buy symbicort over the counter to the public several times over the millennia, but now forgotten. Yet even the government’s knowledge of the burial site is poor. Most records were destroyed in a global war in the year 3112.

It was then that ancient forecasts of the site, found in can i buy symbicort over the counter the 2012 safety case report “Complementary Considerations,” were lost to history. But the farmer does know the mythical stories of Lohikäärme. A dangerous, flying, salmon-colored venomous snake that kills anyone who dares dig too close to his underground cave. She and the other farmers in the area grow crops can i buy symbicort over the counter of peas, sugar beet, and wheat. They balk at the superstitious fools who tell them the monster living beneath their feet is real.

35,012 CE. A tiny microbe floats in a large, northern lake can i buy symbicort over the counter. It does not know that the clay, silt, and mud floor below it is gaining elevation, little by little, year after year. It is unaware that, 30 millennia ago, the lake was a vast sea. Dotted with sailboats, cruise and cargo ships, it was known by can i buy symbicort over the counter humans as the Baltic.

Watery straits, which connected the Baltic Sea to the North Sea, had risen above the water thousands of years ago. Denmark and Sweden fused into a single landmass. The seafloor was decompressing from the Weichselian glaciation—an enormous sheet of can i buy symbicort over the counter ice that pressed down on the land during a previous ice age. After the last human died, the landmass kept on rising. Its uplift was indifferent to human extinction.

It was indifferent to how, in 2013 CE, an anthropologist and a safety case expert sat chatting can i buy symbicort over the counter in white chairs in Ravintola Rytmi. A café in Helsinki. There, the safety case expert relayed his projection that, by 52,000 CE, there would no longer be water separating Turku, Finland, and Stockholm, Sweden. At that point, one could walk from one city to the can i buy symbicort over the counter other on foot. The expert reckoned that, to the north—between Vaasa, Finland, and Umeå, Sweden—one would someday find a waterfall with the planet’s largest deluge of flowing water.

The waterfall could be found at the site of a once-submerged sea shelf. The microbe, though, can i buy symbicort over the counter does not know or care about Vaasa, Umeå, Denmark, long-lost boats, safety case reports, or Helsinki’s past dining options. It has no concept of them. Their significances died with the humans. Nor does the microbe grasp the suffering they faced can i buy symbicort over the counter when succumbing to Anthropocene collapse.

Humans’ past technological feats, grand civilizations, passion projects, intellectual triumphs, wartime sacrifices, and personal struggles are now moot. And yet, the radiological safety of the microbe’s lake’s waters still hinges on the work of a handful of human safety case experts who lived millennia ago. Thinking so far ahead, these experts can i buy symbicort over the counter never lived to see whether their deep time forecasts were accurate. We do not, of course, live in these imagined worlds. In this sense, they are unreal—merely fictions.

However, our capacities to envision potential futures, and to feel empathy can i buy symbicort over the counter for those who may inhabit them, are very real. Depictions of tomorrow can have powerful, concrete effects on the world today. This is why deep time thought experiments are not playful games, but serious acts of intellectual problem-solving. It is why the safety can i buy symbicort over the counter case experts’ models of far future nuclear waste risks are uniquely valuable, even if they are, at the end of the day, mere approximations. Yet pondering distant future Earths can also help us take a step back from our everyday lives—enriching our imaginations by transporting our minds to different places and times.

Corporate coaches have recommended taking breaks from our familiar thinking patterns to experience the world in new ways and overcome mental blocks. Cognitive scientists have shown how creativity can be sparked by perceiving "something one has not seen before (but that was probably always there).” Putting aside a few minutes each day for long-termist, planetary imagination can enrich us with greater mental dexterity in navigating between multiple, can i buy symbicort over the counter interacting timescales. This can cultivate more longsighted empathy for landscapes, people, and other organisms across decades, centuries, and millennia. As the global ecological crisis takes hold, embracing planetary empathy will prove essential to our collective survival. This is an can i buy symbicort over the counter opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American. This essay first appeared in the MIT Reader on August 10, 2021.Beginning in May and appearing to slow down by the end of July, juvenile songbirds from the mid-Atlantic to the Midwest fell ill with odd symptoms and died. Scientists were can i buy symbicort over the counter baffled by the mass mortality event. Months later they still do not know what killed the birds. Suspects include pathogens that the victims could have contracted by consuming Brood X cicadas and environmental toxins to which the young birds were particularly vulnerable.

Brian Evans, an ornithologist at the Smithsonian National Zoo and Conservation Biology Institute in Washington, D.C., is part of a collaborative effort that draws on community science to find out more about the scope of the event and narrow down the possible causes.* Scientific American spoke with Evans about the efforts to solve this can i buy symbicort over the counter ongoing mystery, the impact of community scientists and what the public can do to help. [An edited transcript of the interview follows.] When did you first learn about these songbirds dying?. It first came to my attention in early to mid-May. Early on, can i buy symbicort over the counter I didn’t believe it. I know that fledgling mortality rates are phenomenally high in general.

So to hear word of a bunch of people observing a lot of dead and dying fledglings, as an ornithologist, frankly, didn’t come as much surprise. I had about five birds at that point in my backyard that had basically fallen out of the sky, and I blamed crows because can i buy symbicort over the counter I have an incredible crow population in my neighborhood [in Takoma Park, Md.]. It wasn’t until late May that my perspective on the event had started to change. One of my neighbors observed a bird on the street, out in front of the yard, that was still alive—all the birds that I had encountered at that point were dead—and described it as having really swollen eyes and this inability to respond to her and just [seeming] generally confused. Its head can i buy symbicort over the counter was making tremors.

That seemed to me to be an odd set of symptoms to share. We see a lot of swollen eyes in birds, especially house finches and house sparrows, that are infected with a bacterial called Mycoplasma gallisepticum. But these symptoms that she was describing didn’t can i buy symbicort over the counter sound like [those] caused by mycoplasma. I went from, at that very moment, being really skeptical to starting to doubt myself. Literally a half an hour later, I received a text message from a field technician at the [Smithsonian] Migratory Bird Center with a picture of an affected bird, and a neighbor called me to tell me that he had a bird that was up the road that was sick.

He and I can i buy symbicort over the counter together went to City Wildlife, which is the rehab agency that has been crucial in getting the word out about the event and connecting various parties. They let me know when I went there that, from their perspective, this is a serious event and that they are overwhelmed with the number of mortalities that are coming in. What are the symptoms of this condition, and what birds are affected?. The ophthalmic symptoms can be surprisingly swollen eyes, eyes that jut out of the head a can i buy symbicort over the counter little bit. They can be crusty eyes.

They can be blindness. The neurological symptoms can be things such as a shaking head, an inability can i buy symbicort over the counter to stand, involuntary muscle spasms in general. [They] can be depression or lethargy. When you observe one of these birds with this neurological set of symptoms, it’s fairly obvious, because they’re simply unresponsive. There’s one video that was submitted [via a form that the Smithsonian National Zoo and Conservation Biology Institute set up] of this bird that just had this slow shake to its can i buy symbicort over the counter head and could barely stand and was keeled to the side.

It’s those strange behaviors that I think are most remarkable in this event. To the best of our knowledge, [of those] affected, maybe 90 percent [are] juveniles. It can be tricky to tell a juvenile from an adult, but early on, they can i buy symbicort over the counter look really distinct, especially in regard to plumage, and they have a meaty gape around the corners of their mouth when they’re young in June. What did you do once you realized that these were not run-of-the-mill deaths you would expect among juveniles?. The first thing that we did was start to coordinate with City Wildlife, the rehab group.

We’re sending e-mails back and forth and trying to see can i buy symbicort over the counter. What do we know?. Is this just in [Washington], D.C., or is it in other states?. How many birds can i buy symbicort over the counter are affected?. Are we the worst?.

We took in specimens that have the neurological/ophthalmic symptoms that are associated with the event, and we’re testing them internally through our Center for Conservation Genomics for everything from viral to bacterial to fungal s. The other role I’m playing is reaching out to every rehab agency that I can that has specimens of birds that died from other reasons—so can i buy symbicort over the counter they died because they hit a window or because a cat killed them. Finally, we’re testing truly healthy specimens. We’re going out into the environment, and we’re banding birds and swabbing their eyelids and cloacae. They’ll act can i buy symbicort over the counter as controls for the conservation genomics group.

It’s all about how ... These specimens that are [symptomatic] differ from other specimens in the environment in terms of their microbial community. Why has the agent of disease been so elusive, can i buy symbicort over the counter despite months of this kind of testing?. It’s not just a question of what’s making a given bird sick.... It’s much harder to diagnose a problem that’s shared across a wide geography and a wide timescale and a wide number of species.

What do all of these specimens have in common that are different from healthy birds? can i buy symbicort over the counter. For example, we know a lot tested positive for mycoplasma [bacteria], but we know that a lot of healthy birds test positive for mycoplasma. And not all the birds that we think are associated with this event tested positive for mycoplasma. Something could be affecting the birds neurologically that’s also depressing their immune system, that’s allowing can i buy symbicort over the counter a secondary to come in. What do you think about the hypothesis that the Brood X cicada emergence had something to do with this?.

There are a number of hypotheses for what’s potentially driving the event. Some tests can i buy symbicort over the counter have come back negative. West Nile symbicort, avian flu, salmonella have come back negative. The cicada hypothesis is actually a set of hypotheses that developed because of really strong overlap between the mortality event and the cicada Brood X distribution. Areas that had a lot of cicadas seemed to have a lot of mortalities can i buy symbicort over the counter.

Areas with fewer cicadas seemed to have a lower number of mortalities.... We were always careful to say that correlation isn’t causation in this case—we also know that there are a lot more fledglings in the environment in June, at the peak of cicadas, than there would be in July and August. It’s still a hypothesis that’s on the table, but it’s much less likely can i buy symbicort over the counter now because we’ve found areas that have been impacted with mortalities that did not have Brood X emerge. It seemed like many of the early reports were from amateur birders and community members, and it took ornithologists a bit of time to take these reports seriously. Does that say anything about professional scientists’ relationship to community science?.

I’m sure can i buy symbicort over the counter it does. A lot of my research is associated with community science data, but even I share that skepticism toward community science. I think that this was a lesson to me that we’ve got to do a better job as scientists to listen to what the community is saying. It’s too easy to herald their importance when we agree with what they’re saying or when community scientists are can i buy symbicort over the counter doing as we would wish them to do. When it’s something like this, when community scientists have observed things prior to us making observations, that’s something else entirely.

That’s when the old crotchety scientists in us come in. What have can i buy symbicort over the counter you learned from this experience?. I’m frankly a little ashamed that I was such a cocky bastard at the get-go. It was a real lesson in humility for me. We did this with can i buy symbicort over the counter anti inflammatory drugs.

We too often pretend that something we don’t see isn’t happening. What are the biggest questions about the event that still remain, and do you think we’ll get answers to them?. I can i buy symbicort over the counter think it’ll be solved. To me, the biggest thing to solve first is whether it’s caused by an infectious disease or whether it’s caused by a toxin. Everybody’s champing at the bit to put their bird feeders back up.

I’ve heard so much language and so much can i buy symbicort over the counter pressure—“When can I start feeding birds again?. € And my answer is always “Let’s wait and see what [the U.S. Geological Survey’s National Wildlife Health Center] says.” If it’s an infectious disease, and we care about birds, we shouldn’t be putting our feeders back. It would also can i buy symbicort over the counter be really important to know if it’s an environmental toxin. Why did we see it in 2021—in such large numbers?.

“Will we see it again in the next breeding season?. € is another important can i buy symbicort over the counter question that lingers. You mentioned guidance from USGS that people in some mid-Atlantic, southeastern and Midwest states should take down their birdfeeders. What else can people do?. The most important thing that folks can i buy symbicort over the counter can do is just submit their observations.

I’ve gotten reports from people, both through the bird mortality reporting form and from colleagues, in different states that are outside what’s expected to be the affected area. We need to address whether or not our area of impact is, in fact, accurate. So, for example, if this is occurring in Texas, and Texas does not have Brood can i buy symbicort over the counter X cicadas, that’s a real problem with the cicada hypothesis. Bird enthusiasts should submit their observations and take a lot of pictures and videos of birds. *Editor’s Note (8/13/21).

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Can i take stiolto respimat with symbicort

Meet Joe, whose Doctor has Billed him for the Medicare Coinsurance Joe Client is disabled and has SSD, Medicaid and Qualified can i take stiolto respimat with symbicort Medicare Beneficiary (QMB) site here. His health care is covered by Medicare, and Medicaid and the QMB program pick up his Medicare cost-sharing obligations. Under Medicare Part B, his co-insurance is 20% of the Medicare-approved charge for most outpatient services.

He went to the doctor recently and, can i take stiolto respimat with symbicort as with any other Medicare beneficiary, the doctor handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER.

QMB or Medicaid will pay the Medicare coinsurance only in limited can i take stiolto respimat with symbicort situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage can i take stiolto respimat with symbicort plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers.

Providers may not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since can i take stiolto respimat with symbicort they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article.

CMS can i take stiolto respimat with symbicort is doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here.

See pp can i take stiolto respimat with symbicort. 53, 86. 1.

To Which Providers will QMB or Medicaid Pay can i take stiolto respimat with symbicort the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

2 can i take stiolto respimat with symbicort. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid.

Medicaid is required to pay the provider for all Medicare Part A and B cost-sharing charges for can i take stiolto respimat with symbicort a QMB beneficiary, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary can i take stiolto respimat with symbicort is in a Medicare Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3.

For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be can i take stiolto respimat with symbicort Paid for a QMB or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov.

Cuomo has proposed to reduce how much can i take stiolto respimat with symbicort Medicaid pays for the Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service.

Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible can i take stiolto respimat with symbicort ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital can i take stiolto respimat with symbicort deductible, Medicaid will pay only if six times the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has can i take stiolto respimat with symbicort met the annual deductible, which is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198.

Medicaid pays the entire can i take stiolto respimat with symbicort $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov.

Cuomo proposed to can i take stiolto respimat with symbicort reduce the amount Medicaid pays toward the deductible to the same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, can i take stiolto respimat with symbicort QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

Exceptions - Medicaid/QMB can i take stiolto respimat with symbicort wil pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32).

SSL 367-a, subd can i take stiolto respimat with symbicort. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case.

This would have deterred doctors and can i take stiolto respimat with symbicort other providers from being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016.

EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016).

Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment.

Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. .

4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A).

In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at.

CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.

Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5.

How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider.

Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability.

The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

Unfortunately, the Medicaid card does not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB.

See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. What Codes the Provider Sees in eMedNY &.

EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) ​​​​​​​Recipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces. "Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P.

*Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down. See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P.

"Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26.

2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372.

Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs.

Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link.

Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts.

Author. Geoffrey Hale This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021.

MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits.

MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program.

In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP.

Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example.

Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies.

$400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP.

2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time.

This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB.

If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting.

During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS.

The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd.

4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during anti inflammatory drugs emergency their case may remain with NYSoH for more than 12 months.

See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note.

During the anti inflammatory drugs emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on anti inflammatory drugs eligibility changes 4.

Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit.

If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down.

Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP.

If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8).

When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium.

See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check.

In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility.

There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V).

If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777.

Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS.

Once enrolled, it make take a few months for payments to begin.

He went to the doctor recently Online kamagra prescription and, as with any other Medicare beneficiary, the doctor can i buy symbicort over the counter handed him a bill for his co-pay. Now Joe has a bill that he can’t pay. Read below to find out -- SHORT ANSWER.

QMB or Medicaid will can i buy symbicort over the counter pay the Medicare coinsurance only in limited situations. First, the provider must be a Medicaid provider. Second, even if the provider accepts Medicaid, under recent legislation in New York enacted in 2015 and 2016, QMB or Medicaid may pay only part of the coinsurance, or none at all.

This depends in part on whether the beneficiary has Original Medicare or is in a Medicare Advantage can i buy symbicort over the counter plan, and in part on the type of service. However, the bottom line is that the provider is barred from "balance billing" a QMB beneficiary for the Medicare coinsurance. Unfortunately, this creates tension between an individual and her doctors, pharmacies dispensing Part B medications, and other providers.

Providers may can i buy symbicort over the counter not know they are not allowed to bill a QMB beneficiary for Medicare coinsurance, since they bill other Medicare beneficiaries. Even those who know may pressure their patients to pay, or simply decline to serve them. These rights and the ramifications of these QMB rules are explained in this article.

CMS is can i buy symbicort over the counter doing more education about QMB Rights. The Medicare Handbook, since 2017, gives information about QMB Protections. Download the 2020 Medicare Handbook here.

See pp can i buy symbicort over the counter. 53, 86. 1.

To Which can i buy symbicort over the counter Providers will QMB or Medicaid Pay the Medicare Co-Insurance?. "Providers must enroll as Medicaid providers in order to bill Medicaid for the Medicare coinsurance." CMS Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs). The CMS bulletin states, "If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules." If the provider chooses not to enroll as a Medicaid provider, they still may not "balance bill" the QMB recipient for the coinsurance.

2 can i buy symbicort over the counter. How Does a Provider that DOES accept Medicaid Bill for a QMB Beneficiary?. If beneficiary has Original Medicare -- The provider bills Medicaid - even if the QMB Beneficiary does not also have Medicaid.

Medicaid is required can i buy symbicort over the counter to pay the provider for all Medicare Part A and B cost-sharing charges for a QMB beneficiary, even if the service is normally not covered by Medicaid (ie, chiropractic, podiatry and clinical social work care). Whatever reimbursement Medicaid pays the provider constitutes by law payment in full, and the provider cannot bill the beneficiary for any difference remaining. 42 U.S.C.

§ 1396a(n)(3)(A), NYS DOH 2000-ADM-7 If the QMB beneficiary is in a Medicare can i buy symbicort over the counter Advantage plan - The provider bills the Medicare Advantage plan, then bills Medicaid for the balance using a “16” code to get paid. The provider must include the amount it received from Medicare Advantage plan. 3.

For a Provider who accepts Medicaid, How Much of the Medicare Coinsurance will be Paid for a QMB can i buy symbicort over the counter or Medicaid Beneficiary in NYS?. The answer to this question has changed by laws enacted in 2015 and 2016. In the proposed 2019 State Budget, Gov.

Cuomo has proposed to reduce how much Medicaid pays for the can i buy symbicort over the counter Medicare costs even further. The amount Medicaid pays is different depending on whether the individual has Original Medicare or is a Medicare Advantage plan, with better payment for those in Medicare Advantage plans. The answer also differs based on the type of service.

Part A Deductibles and Coinsurance - Medicaid pays the full Part A hospital deductible can i buy symbicort over the counter ($1,408 in 2020) and Skilled Nursing Facility coinsurance ($176/day) for days 20 - 100 of a rehab stay. Full payment is made for QMB beneficiaries and Medicaid recipients who have no spend-down. Payments are reduced if the beneficiary has a Medicaid spend-down.

For in-patient hospital deductible, Medicaid will pay only if six times can i buy symbicort over the counter the monthly spend-down has been met. For example, if Mary has a $200/month spend down which has not been met otherwise, Medicaid will pay only $164 of the hospital deductible (the amount exceeding 6 x $200). See more on spend-down here.

Medicare Part B - Deductible - Currently, Medicaid pays the full Medicare approved charges until the beneficiary has met the annual deductible, which can i buy symbicort over the counter is $198 in 2020. For example, Dr. John charges $500 for a visit, for which the Medicare approved charge is $198.

Medicaid pays the can i buy symbicort over the counter entire $198, meeting the deductible. If the beneficiary has a spend-down, then the Medicaid payment would be subject to the spend-down. In the 2019 proposed state budget, Gov.

Cuomo proposed to reduce the amount Medicaid pays toward the deductible to the can i buy symbicort over the counter same amount paid for coinsurance during the year, described below. This proposal was REJECTED by the state legislature. Co-Insurance - The amount medicaid pays in NYS is different for Original Medicare and Medicare Advantage.

If individual has Original Medicare, QMB/Medicaid will pay the 20% Part B coinsurance only to the extent the total combined payment the provider receives can i buy symbicort over the counter from Medicare and Medicaid is the lesser of the Medicaid or Medicare rate for the service. For example, if the Medicare rate for a service is $100, the coinsurance is $20. If the Medicaid rate for the same service is only $80 or less, Medicaid would pay nothing, as it would consider the doctor fully paid = the provider has received the full Medicaid rate, which is lesser than the Medicare rate.

Exceptions - Medicaid/QMB wil pay the full coinsurance for the following can i buy symbicort over the counter services, regardless of the Medicaid rate. ambulance and psychologists - The Gov's 2019 proposal to eliminate these exceptions was rejected. hospital outpatient clinic, certain facilities operating under certificates issued under the Mental Hygiene Law for people with developmental disabilities, psychiatric disability, and chemical dependence (Mental Hygiene Law Articles 16, 31 or 32).

SSL 367-a, can i buy symbicort over the counter subd. 1(d)(iii)-(v) , as amended 2015 If individual is in a Medicare Advantage plan, 85% of the copayment will be paid to the provider (must be a Medicaid provider), regardless of how low the Medicaid rate is. This limit was enacted in the 2016 State Budget, and is better than what the Governor proposed - which was the same rule used in Original Medicare -- NONE of the copayment or coinsurance would be paid if the Medicaid rate was lower than the Medicare rate for the service, which is usually the case.

This would have deterred doctors and other providers from can i buy symbicort over the counter being willing to treat them. SSL 367-a, subd. 1(d)(iv), added 2016.

EXCEPTIONS. The Medicare Advantage plan must pay the full coinsurance for the following services, regardless of the Medicaid rate. ambulance ) psychologist ) The Gov's proposal in the 2019 budget to eliminate these exceptions was rejected by the legislature Example to illustrate the current rules.

The Medicare rate for Mary's specialist visit is $185. The Medicaid rate for the same service is $120. Current rules (since 2016).

Medicare Advantage -- Medicare Advantage plan pays $135 and Mary is charged a copayment of $50 (amount varies by plan). Medicaid pays the specialist 85% of the $50 copayment, which is $42.50. The doctor is prohibited by federal law from "balance billing" QMB beneficiaries for the balance of that copayment.

Since provider is getting $177.50 of the $185 approved rate, provider will hopefully not be deterred from serving Mary or other QMBs/Medicaid recipients. Original Medicare - The 20% coinsurance is $37. Medicaid pays none of the coinsurance because the Medicaid rate ($120) is lower than the amount the provider already received from Medicare ($148).

For both Medicare Advantage and Original Medicare, if the bill was for a ambulance or psychologist, Medicaid would pay the full 20% coinsurance regardless of the Medicaid rate. The proposal to eliminate this exception was rejected by the legislature in 2019 budget. .

4. May the Provider 'Balance Bill" a QMB Benficiary for the Coinsurance if Provider Does Not Accept Medicaid, or if Neither the Patient or Medicaid/QMB pays any coinsurance?. No.

Balance billing is banned by the Balanced Budget Act of 1997. 42 U.S.C. § 1396a(n)(3)(A).

In an Informational Bulletin issued January 6, 2012, titled "Billing for Services Provided to Qualified Medicare Beneficiaries (QMBs)," the federal Medicare agency - CMS - clarified that providers MAY NOT BILL QMB recipients for the Medicare coinsurance. This is true whether or not the provider is registered as a Medicaid provider. If the provider wants Medicaid to pay the coinsurance, then the provider must register as a Medicaid provider under the state rules.

This is a change in policy in implementing Section 1902(n)(3)(B) of the Social Security Act (the Act), as modified by section 4714 of the Balanced Budget Act of 1997, which prohibits Medicare providers from balance-billing QMBs for Medicare cost-sharing. The CMS letter states, "All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs are prohibited from billing QMBs for Medicare cost-sharing, including deductible, coinsurance, and copayments. This section of the Act is available at.

CMCS Informational Bulletin http://www.ssa.gov/OP_Home/ssact/title19/1902.htm. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.

Please note that the statute referenced above supersedes CMS State Medicaid Manual, Chapter 3, Eligibility, 3490.14 (b), which is no longer in effect, but may be causing confusion about QMB billing." The same information was sent to providers in this Medicare Learning Network bulletin, last revised in June 26, 2018. CMS reminded Medicare Advantage plans of the rule against Balance Billing in the 2017 Call Letter for plan renewals. See this excerpt of the 2017 call letter by Justice in Aging - Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing 5.

How do QMB Beneficiaries Show a Provider that they have QMB and cannot be Billed for the Coinsurance?. It can be difficult to show a provider that one is a QMB. It is especially difficult for providers who are not Medicaid providers to identify QMB's, since they do not have access to online Medicaid eligibility systems Consumers can now call 1-800-MEDICARE to verify their QMB Status and report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Medicare Summary Notices (MSNs) that Medicare beneficiaries receive every three months state that QMBs have no financial liability for co-insurance for each Medicare-covered service listed on the MSN. The Remittance Advice (RA) that Medicare sends to providers shows the same information. By spelling out billing protections on a service-by-service basis, the MSNs provide clarity for both the QMB beneficiary and the provider.

Justice in Aging has posted samples of what the new MSNs look like here. They have also updated Justice in Aging’s Improper Billing Toolkit to incorporate references to the MSNs in its model letters that you can use to advocate for clients who have been improperly billed for Medicare-covered services. CMS is implementing systems changes that will notify providers when they process a Medicare claim that the patient is QMB and has no cost-sharing liability.

The Medicare Summary Notice sent to the beneficiary will also state that the beneficiary has QMB and no liability. These changes were scheduled to go into effect in October 2017, but have been delayed. Read more about them in this Justice in Aging Issue Brief on New Strategies in Fighting Improper Billing for QMBs (Feb.

2017). QMBs are issued a Medicaid benefit card (by mail), even if they do not also receive Medicaid. The card is the mechanism for health care providers to bill the QMB program for the Medicare deductibles and co-pays.

Unfortunately, the Medicaid card does not indicate QMB eligibility. Not all people who have Medicaid also have QMB (they may have higher incomes and "spend down" to the Medicaid limits. Advocates have asked for a special QMB card, or a notation on the Medicaid card to show that the individual has QMB.

See this Report - a National Survey on QMB Identification Practices published by Justice in Aging, authored by Peter Travitsky, NYLAG EFLRP staff attorney. The Report, published in March 2017, documents how QMB beneficiaries could be better identified in order to ensure providers do not bill them improperly. What Codes the Provider Sees in eMedNY &.

EPACES Medicaid eligibility system - see GIS 16 MA/005 - Changes to eMedNY for Certain Medicaid Recipient Coverage Codes (PDF) ​​​​​​​Recipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces. "Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P.

*Code 06 is "provisional Medicaid coverage" for Medicaid recipients found provisionally eligible for Medicaid, subject to meeting the spend-down. See more about provisional coverage here. "Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P.

"Code 18" is for Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP), who are also income eligible for QMB. 6. If you are Billed -​ Strategies Consumers can now call 1-800-MEDICARE to report a billing issue.

If a consumer reports a balance billng problem to this number, the Customer Service Rep can escalate the complaint to the Medicare Administrative Contractor (MAC), which will send a compliance letter to the provider with a copy to the consumer. See CMS Medicare Learning Network Bulletin effective Dec. 16, 2016.

Send a letter to the provider, using the Justice In Aging Model model letters to providers to explain QMB rights.​​​ both for Original Medicare (Letters 1-2) and Medicare Advantage (Letters 3-5) - see Overview of model letters. Include a link to the CMS Medicare Learning Network Notice. Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (revised June 26.

2018) In January 2017, the Consumer Finance Protection Bureau issued this guide to QMB billing. A consumer who has a problem with debt collection, may also submit a complaint online or call the CFPB at 1-855-411-2372. TTY/TDD users can call 1-855-729-2372.

Medicare Advantage members should complain to their Medicare Advantage plan. In its 2017 Call Letter, CMS stressed to Medicare Advantage contractors that federal regulations at 42 C.F.R. § 422.504 (g)(1)(iii), require that provider contracts must prohibit collection of deductibles and co-payments from dual eligibles and QMBs.

Toolkit to Help Protect QMB Rights ​​In July 2015, CMS issued a report, "Access to Care Issues Among Qualified Medicare Beneficiaries (QMB's)" documenting how pervasive illegal attempts to bill QMBs for the Medicare coinsurance, including those who are members of managed care plans. Justice in Aging, a national advocacy organization, has a project to educate beneficiaries about balance billing and to advocate for stronger protections for QMBs. Links to their webinars and other resources is at this link.

Their information includes. September 4, 2009, updated 6/20/20 by Valerie Bogart, NYLAG Author. Cathy Roberts.

Author. Geoffrey Hale This article was authored by the Empire Justice Center.Some "dual eligible" beneficiaries (people who have Medicare and Medicaid) are entitled to receive reimbursement of their Medicare Part B premiums from New York State through the Medicare Insurance Premium Payment Program (MIPP). The Part B premium is $148.50 in 2021.

MIPP is for some groups who are either not eligible for -- or who are not yet enrolled in-- the Medicare Savings Program (MSP), which is the main program that pays the Medicare Part B premium for low-income people. Some people are not eligible for an MSP even though they have full Medicaid with no spend down. This is because they are in a special Medicaid eligibility category -- discussed below -- with Medicaid income limits that are actually HIGHER than the MSP income limits.

MIPP reimburses them for their Part B premium because they have “full Medicaid” (no spend down) but are ineligible for MSP because their income is above the MSP SLIMB level (120% of the Federal Poverty Level (FPL). Even if their income is under the QI-1 MSP level (135% FPL), someone cannot have both QI-1 and Medicaid). Instead, these consumers can have their Part B premium reimbursed through the MIPP program.

In this article. The MIPP program was established because the State determined that those who have full Medicaid and Medicare Part B should be reimbursed for their Part B premium, even if they do not qualify for MSP, because Medicare is considered cost effective third party health insurance, and because consumers must enroll in Medicare as a condition of eligibility for Medicaid (See 89 ADM 7). There are generally four groups of dual-eligible consumers that are eligible for MIPP.

Therefore, many MBI WPD consumers have incomes higher than what MSP normally allows, but still have full Medicaid with no spend down. Those consumers can qualify for MIPP and have their Part B premiums reimbursed. Here is an example.

Sam is age 50 and has Medicare and MBI-WPD. She gets $1500/mo gross from Social Security Disability and also makes $400/month through work activity. $ 167.50 -- EARNED INCOME - Because she is disabled, the DAB earned income disregard applies.

$400 - $65 = $335. Her countable earned income is 1/2 of $335 = $167.50 + $1500.00 -- UNEARNED INCOME from Social Security Disability = $1,667.50 --TOTAL income. This is above the SLIMB limit of $1,288 (2021) but she can still qualify for MIPP.

2. Parent/Caretaker Relatives with MAGI-like Budgeting - Including Medicare Beneficiaries. Consumers who fall into the DAB category (Age 65+/Disabled/Blind) and would otherwise be budgeted with non-MAGI rules can opt to use Affordable Care Act MAGI rules if they are the parent/caretaker of a child under age 18 or under age 19 and in school full time.

This is referred to as “MAGI-like budgeting.” Under MAGI rules income can be up to 138% of the FPL—again, higher than the limit for DAB budgeting, which is equivalent to only 83% FPL. MAGI-like consumers can be enrolled in either MSP or MIPP, depending on if their income is higher or lower than 120% of the FPL. If their income is under 120% FPL, they are eligible for MSP as a SLIMB.

If income is above 120% FPL, then they can enroll in MIPP. (See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4) 3. New Medicare Enrollees who are Not Yet in a Medicare Savings Program When a consumer has Medicaid through the New York State of Health (NYSoH) Marketplace and then enrolls in Medicare when she turns age 65 or because she received Social Security Disability for 24 months, her Medicaid case is normally** transferred to the local department of social services (LDSS)(HRA in NYC) to be rebudgeted under non-MAGI budgeting.

During the transition process, she should be reimbursed for the Part B premiums via MIPP. However, the transition time can vary based on age. AGE 65+ For those who enroll in Medicare at age 65+, the Medicaid case takes about four months to be rebudgeted and approved by the LDSS.

The consumer is entitled to MIPP payments for at least three months during the transition. Once the case is with the LDSS she should automatically be re-evaluated for MSP. Consumers UNDER 65 who receive Medicare due to disability status are entitled to keep MAGI Medicaid through NYSoH for up to 12 months (also known as continuous coverage, See NY Social Services Law 366, subd.

4(c). These consumers should receive MIPP payments for as long as their cases remain with NYSoH and throughout the transition to the LDSS. NOTE during anti inflammatory drugs emergency their case may remain with NYSoH for more than 12 months.

See here. See GIS 18 MA/001 - 2018 Medicaid Managed Care Transition for Enrollees Gaining Medicare, #4 for an explanation of this process. Note.

During the anti inflammatory drugs emergency, those who have Medicaid through the NYSOH marketplace and enroll in Medicare should NOT have their cases transitioned to the LDSS. They should keep the same MAGI budgeting and automatically receive MIPP payments. See GIS 20 MA/04 or this article on anti inflammatory drugs eligibility changes 4.

Those with Special Budgeting after Losing SSI (DAC, Pickle, 1619b) Disabled Adult Child (DAC). Special budgeting is available to those who are 18+ and lose SSI because they begin receiving Disabled Adult Child (DAC) benefits (or receive an increase in the amount of their benefit). Consumer must have become disabled or blind before age 22 to receive the benefit.

If the new DAC benefit amount was disregarded and the consumer would otherwise be eligible for SSI, they can keep Medicaid eligibility with NO SPEND DOWN. See this article. Consumers may have income higher than MSP limits, but keep full Medicaid with no spend down.

Therefore, they are eligible for payment of their Part B premiums. See page 96 of the Medicaid Reference Guide (Categorical Factors). If their income is lower than the MSP SLIMB threshold, they can be added to MSP.

If higher than the threshold, they can be reimbursed via MIPP. See also 95-ADM-11. Medical Assistance Eligibility for Disabled Adult Children, Section C (pg 8).

When the Part B Premium Reduces Countable Income to Below the Medicaid Limit Since the Part B premium can be used as a deduction from gross income, it may reduce someone's countable income to below the Medicaid limit. The consumer should be paid the difference to bring her up to the Medicaid level ($904/month in 2021). They will only be reimbursed for the difference between their countable income and $904, not necessarily the full amount of the premium.

See GIS 02-MA-019. Reimbursement of Health Insurance Premiums MIPP and MSP are similar in that they both pay for the Medicare Part B premium, but there are some key differences. MIPP structures the payments as reimbursement -- beneficiaries must continue to pay their premium (via a monthly deduction from their Social Security check or quarterly billing, if they do not receive Social Security) and then are reimbursed via check.

In contrast, MSP enrollees are not charged for their premium. Their Social Security check usually increases because the Part B premium is no longer withheld from their check. MIPP only provides reimbursement for Part B.

It does not have any of the other benefits MSPs can provide, such as. A consumer cannot have MIPP without also having Medicaid, whereas MSP enrollees can have MSP only. Of the above benefits, Medicaid also provides Part D Extra Help automatic eligibility.

There is no application process for MIPP because consumers should be screened and enrolled automatically (00 OMM/ADM-7). Either the state or the LDSS is responsible for screening &. Distributing MIPP payments, depending on where the Medicaid case is held and administered (14 /2014 LCM-02 Section V).

If a consumer is eligible for MIPP and is not receiving it, they should contact whichever agency holds their case and request enrollment. Unfortunately, since there is no formal process for applying, it may require some advocacy. If Medicaid case is at New York State of Health they should call 1-855-355-5777.

Consumers will likely have to ask for a supervisor in order to find someone familiar with MIPP. If Medicaid case is with HRA in New York City, they should email mipp@hra.nyc.gov. If Medicaid case is with other local districts in NYS, call your local county DSS.

Once enrolled, it make take a few months for payments to begin. Payments will be made in the form of checks from the Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid program. The check itself comes attached to a remittance notice from Medicaid Management Information Systems (MMIS).

Unfortunately, the notice is not consumer-friendly and may be confusing.

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N/A 2018-08-17 2024-08-17 N/A 2026-08-17 bazedoxifene acetate symbicort steroid inhaler side effects 160681 Duavive Pfizer Canada Inc. N/A 2014-10-23 2020-10-23 N/A 2022-10-23 benralizumab 204008 Fasenra AstraZeneca Canada Inc. N/A 2018-02-22 2024-02-22 Yes 2026-08-22 bepotastine besilate 179294 Bepreve Bausch and Lomb Incorporated N/A 2016-07-27 2022-07-27 Yes 2025-01-27 bictegravir 203718 Biktarvy Gilead Sciences Canada, Inc. N/A 2018-07-10 2024-07-10 Yes 2027-01-10 bilastine symbicort steroid inhaler side effects 184231 Blexten Aralez Pharmaceutials Canada Inc.

N/A 2016-04-21 2022-04-21 Yes 2024-10-21 binimetinib 237410 Mektovi Pfizer Canada ULC N/A 2021-03-02 2027-03-02 N/A 2029-03-02 blinatumomab 181723 Blincyto Amgen Canada Incorporated N/A 2015-12-22 2021-12-22 Yes 2024-06-22 bosutinib 152211 Bosulif Pfizer Canada Inc. N/A 2014-03-07 2020-03-07 symbicort steroid inhaler side effects N/A 2022-03-07 botulism antitoxin heptavalen C/ D/ F/ G - (equine) 190645 Bat Emergent BioSolutions Inc. N/A 2016-12-08 2022-12-08 Yes 2025-06-08 brexpiprazole 192684 Rexulti Otsuka Pharmaceutical Co. Ltd.

N/A 2017-02-16 2023-02-16 Yes 2025-08-16 brexucabtagene autoleucel 246355 Tecartus symbicort steroid inhaler side effects Gilead Sciences Canada, Inc. N/A 2021-06-08 2027-06-08 N/A 2029-06-08 brigatinib 210369 Alunbrig Takeda Canada Incorporated N/A 2018-07-26 2024-07-26 N/A 2026-07-26 brivaracetam 183355 Brivlera UCB Canada Incorporated N/A 2016-03-09 2022-03-09 Yes 2024-09-09 brodalumab 195317 Siliq Bausch Health, Canada Inc. N/A 2018-03-06 2024-03-06 N/A 2026-03-06 brolucizumab 226224 Beovu Novartis Pharmaceuticals Canada Inc. N/A 2020-03-12 2026-03-12 N/A 2028-03-12 bromfenac sodium sesquihydrate symbicort steroid inhaler side effects 171657 Prolensa Bausch &.

Lomb Incorporated N/A 2015-03-26 2021-03-26 N/A 2023-03-26 burosumab 216239 Crysvita Kyowa Kirin Limited N/A 2018-12-05 2024-12-05 Yes 2027-06-05 cabotegravir sodium 227315 Vocabria ViiV Healthcare ULC N/A 2020-03-18 2026-03-18 N/A 2028-03-18 cabotegravir 227315 Cabenuva ViiV Healthcare ULC N/A 2020-03-18 2026-03-18 N/A 2028-03-18 cabozantinib (supplied as cabozantinib (S)-malate) 206230 Cabometyx Ipsen Biopharmaceuticals Canada Inc. N/A 2018-09-14 2024-09-14 N/A 2026-09-14 calcifediol 205392 Rayaldee Vifor Fresenius Medical Care Renal Pharma Ltd N/A 2018-07-10 2024-07-10 N/A 2026-07-10 canagliflozin 157505 Invokana Janssen Inc. InvokametInvokamet XR 2014-05-23 2020-05-23 N/A 2022-05-23 caplacizumab 230001 Cablivi Sanofi-Aventis Canada symbicort steroid inhaler side effects Inc. N/A 2020-02-28 2026-02-28 N/A 2028-02-28 carfilzomib 184479 Kyprolis Amgen Canada Inc.

N/A 2016-01-15 2022-01-15 N/A 2024-01-15 carglumic acid 171358 Carbaglu Recordati Rare Diseases N/A 2015-04-10 2021-04-10 Yes 2023-10-10 cedazuridine 234610 Inqovi Otsuka Pharmaceutical Co., Ltd. N/A 2020-07-07 2026-07-07 N/A 2028-07-07 ceftolozane 178006 Zerbaxa Merck symbicort steroid inhaler side effects Canada Inc. N/A 2015-09-30 2021-09-30 N/A 2023-09-30 cemiplimab 218718 Libtayo Sanofi-Aventis Canada Inc. N/A 2019-04-10 2025-04-10 N/A 2027-04-10 cenegermin 218145 Oxervate Dompé farmaceutici S.p.A.

N/A 2019-02-08 2025-02-08 N/A 2027-02-08 ceritinib 175702 Zykadia Novartis Pharmaceuticals Canada Inc symbicort steroid inhaler side effects. N/A 2015-03-27 2021-03-27 N/A 2023-03-27 cerliponase alfa 216539 Brineura Biomarin International Limited N/A 2018-12-19 2024-12-19 Yes 2027-06-19 coagulation factor IX (recombinant), albumin fusion protein (rIX-FP) 180793 Idelvion CSL Behring Canada Inc. N/A 2016-01-26 2022-01-26 Yes 2024-07-26 coagulation factor IX (recombinant), pegylated (nonacog beta pegol) 201114 symbicort steroid inhaler side effects Rebinyn Novo Nordisk Canada Inc. N/A 2017-11-29 2023-11-29 Yes 2026-05-29 coagulation factor IX, Fc fusion protein 163614 Alprolix Sanofi-Aventis Canada Inc.

N/A 2014-03-20 2020-03-20 Yes 2022-09-20 cobimetinib 182788 Cotellic Hoffmann-La Roche Limited N/A 2016-02-22 2022-02-22 N/A 2024-02-22 crisaborole 206906 Eucrisa Pfizer Canada Inc. N/A 2018-06-07 2024-06-07 Yes 2026-12-07 cysteamine bitartrate 191347 Procysbi Horizon symbicort steroid inhaler side effects Pharma Ireland Ltd. N/A 2017-06-13 2023-06-13 Yes 2025-12-13 daclatasvir 172616 Daklinza Bristol-Myers Squibb Canada N/A 2015-08-13 2021-08-13 N/A 2023-08-13 daclizumab beta 190458 Zinbryta Biogen Canada Inc. N/A 2016-12-08 2022-12-08 N/A 2024-12-08 dacomitinib 214572 Vizimpro Pfizer Canada Inc.

N/A 2019-02-26 2025-02-26 N/A 2027-02-26 dalbavancin symbicort steroid inhaler side effects (supplied as dalbavancin hydrochloride) 212390 Xydalba Cipher Pharmaceuticals Inc. N/A 2018-09-04 2024-09-04 N/A 2026-09-04 dapagliflozin propanediol 160877 Forxiga AstraZeneca Canada Inc. XigduoQtern 2014-12-12 2020-12-12 N/A 2022-12-12 daratumumab 187648 Darzalex Janssen Inc. Darzalex SC 2016-06-29 2022-06-29 N/A 2024-06-29 darolutamide 226146 Nubeqa Bayer symbicort steroid inhaler side effects Inc.

N/A 2020-02-20 2026-02-20 N/A 2028-02-20 deferiprone 162924 Ferriprox Chiesi Canada Corp. N/A 2015-02-13 2021-02-13 Yes 2023-08-13 defibrotide sodium 200808 Defitelio Jazz Pharmaceuticals Ireland Limited N/A 2017-07-10 2023-07-10 Yes 2026-01-10 difluprednate 154517 Durezol Novartis Pharmaceuticals Canada Inc. N/A 2013-11-04 2019-11-04 Yes 2022-05-04 dimethyl fumarate 154776 Tecfidera Biogen Idec Canada symbicort steroid inhaler side effects Inc. N/A 2013-04-03 2019-04-03 Yes 2021-10-03 dinutuximab 212066 Unituxin United Therapeutics Corporation N/A 2018-11-28 2024-11-28 Yes 2027-05-28 dolutegravir sodium 161084 Tivicay ViiV Healthcare ULC TriumeqJulucaDovato 2013-10-31 2019-10-31 Yes 2022-05-01 doravirine 211293 Pifeo Merck Canada Inc.

Delstrigo 2018-10-12 2024-10-12 N/A 2026-10-12 dulaglutide 168671 Trulicity Eli Lilly Canada Inc. N/A 2015-11-10 2021-11-10 N/A symbicort steroid inhaler side effects 2023-11-10 dupilumab 201285 Dupixent Sanofi-Aventis Canada Inc. N/A 2017-11-30 2023-11-30 Yes 2026-05-30 durvalumab 202953 Imfinzi AstraZeneca Canada Inc. N/A 2017-11-03 2023-11-03 N/A symbicort steroid inhaler side effects 2025-11-03 edaravone 214391 Radicava Mitsubishi Tanabe Pharma Corporation N/A 2018-10-03 2024-10-03 N/A 2026-10-03 edoxaban 187363 Lixiana Servier Canada Inc.

N/A 2016-11-04 2022-11-04 N/A 2024-11-04 efinaconazole 159416 Jublia Bausch Health, Canada Inc. N/A 2013-10-02 2019-10-02 N/A 2021-10-02 elagolix 209513 Orilissa AbbVie Corporation N/A 2018-10-05 2024-10-05 N/A 2026-10-05 elexacaftor 246955 Trikafta Vertex Pharmaceuticals (Canada) Incorporated N/A 2021-06-18 2027-06-18 Yes 2029-12-18 eliglustat tartrate 183050 Cerdelga Genzyme Canada, A division of Sanofi-aventis Canada Inc. N/A 2017-04-21 2023-04-21 N/A 2025-04-21 elosulfase alfa 170340 Vimizim Biomarin International Limited N/A 2014-07-02 2020-07-02 Yes 2023-01-02 elotuzumab symbicort steroid inhaler side effects 188144 Empliciti Bristol-Myers Squibb Canada N/A 2016-06-21 2022-06-21 N/A 2024-06-21 eluxadoline 190162 Viberzi Allergan inc. N/A 2017-01-26 2023-01-26 N/A 2025-01-26 emicizumab 212635 Hemlibra Hoffmann-La Roche Limited N/A 2018-08-02 2024-08-02 Yes 2027-02-02 empagliflozin 162552 Jardiance Boehringer Ingelheim (Canada) Ltd.

SynjardyGlyxambi 2015-07-23 2021-07-23 N/A 2023-07-23 enasidenib mesylate 217033 Idhifa Celgene Inc. N/A 2019-02-06 2025-02-06 N/A 2027-02-06 encorafenib 237413 Braftovi Pfizer Canada ULC N/A 2021-03-02 2027-03-02 N/A 2029-03-02 entrectinib symbicort steroid inhaler side effects 227517 Rozlytrek Hoffmann-La Roche Limited N/A 2020-02-10 2026-02-10 Yes 2028-08-10 eptinezumab 233288 Vyepti Lundbeck Canada Inc. N/A 2021-01-11 2027-01-11 N/A 2029-01-11 erdafitinib 224529 Balversa Janssen Inc. N/A 2019-10-25 2025-10-25 N/A 2027-10-25 erenumab 208607 Aimovig Novartis Pharmaceuticals Canada Inc.

N/A 2018-08-01 2024-08-01 N/A 2026-08-01 ertugliflozin symbicort steroid inhaler side effects 204724 Steglatro Merck Canada Inc. SteglujanSegluromet 2018-05-09 2024-05-09 N/A 2026-05-09 eslicarbazepine acetate 165665 Aptiom Sunovion Pharmaceuticals Canada Inc. N/A 2014-07-08 2020-07-08 Yes 2023-01-08 estetrol monohydrate 236197 Nextstellis Searchlight Pharma Inc. N/A 2021-03-05 symbicort steroid inhaler side effects 2027-03-05 N/A 2029-03-05 evolocumab 178234 Repatha Amgen Canada Inc.

N/A 2015-09-10 2021-09-10 Yes 2024-03-10 fedratinib (supplied as fedratinib hydrochloride) 229866 Inrebic Celgene Inc. N/A 2020-07-27 2026-07-27 N/A 2028-07-27 ferric pyrophosphate citrate 239850 Triferic Avnu Rockwell Medical Inc. N/A 2021-04-22 2027-04-22 Yes 2029-10-22 finafloxacin 172450 Xtoro MerLion symbicort steroid inhaler side effects Pharmaceuticals GmbH N/A 2016-03-11 2022-03-11 Yes 2024-09-11 flibanserin 189352 Addyi Searchlight Pharma Inc. N/A 2018-02-27 2024-02-27 N/A 2026-02-27 florbetaben (18F) 193105 Neuraceq Isologic Innovative Radiopharmaceuticals Ltd.

N/A 2017-02-22 2023-02-22 symbicort steroid inhaler side effects N/A 2025-02-22 follitropin delta 188743 Rekovelle Ferring Inc. N/A 2018-03-22 2024-03-22 N/A 2026-03-22 fostamatinib (supplied as fostamatinib disodium) 232078 Tavalisse Medison Pharma Canada Inc. N/A 2020-11-19 2026-11-19 N/A 2028-11-19 fremanezumab 226828 Ajovy Teva Canada Limited N/A 2020-04-09 2026-04-09 N/A 2028-04-09 gadoterate meglumine 186333 Dotarem Guerbet N/A 2016-11-26 2022-11-26 Yes 2025-05-26 galcanezumab 219521 Emgality Eli Lilly Canada Inc. N/A 2019-07-30 2025-07-30 N/A 2027-07-30 galsulfase 159020 Naglazyme BioMarin Pharmaceutical Inc symbicort steroid inhaler side effects.

N/A 2013-09-16 2019-09-16 Yes 2022-03-16 gemtuzumab ozogamicin 223091 Mylotarg Pfizer Canada ULC N/A 2019-11-28 2025-11-28 Yes 2028-05-28 gilteritinib fumarate 227918 Xospata Astellas Pharma Canada Inc. N/A 2019-12-23 2025-12-23 N/A 2027-12-23 givosiran (supplied as givosiran sodium) 237194 Givlaari Alnylam Netherlands B.V.. N/A 2020-10-09 symbicort steroid inhaler side effects 2026-10-09 N/A 2028-10-09 glasdegib 225793 Daurismo Pfizer Canada ULC N/A 2020-04-28 2026-04-28 N/A 2028-04-28 glecaprevir, pibrentasvir 202233 Maviret AbbVie Corporation N/A 2017-08-16 2023-08-16 Yes 2026-02-16 glycerol phenylbutyrate 174219 Ravicti Horizon Pharma Ireland Ltd. N/A 2016-03-18 2022-03-18 Yes 2024-09-18 grazoprevir, elbasvir 185866 Zepatier Merck Canada Inc.

N/A 2016-01-19 2022-01-19 N/A 2024-01-19 guanfacine hydrochloride 150741 Intuniv XR Takeda Canada Inc. N/A 2013-07-05 symbicort steroid inhaler side effects 2019-07-05 Yes 2022-01-05 guselkumab 200590 Tremfya Janssen Inc. N/A 2017-11-10 2023-11-10 N/A 2025-11-10 hemin 212276 Panhematin Recordati Rare Diseases Canada Inc. N/A 2018-07-13 2024-07-13 N/A 2026-07-13 ibrutinib 174029 Imbruvica Janssen Inc.

N/A 2014-11-17 2020-11-17 Yes 2023-05-17 icatibant acetate 162918 symbicort steroid inhaler side effects Firazyr Takeda Canada Inc. N/A 2014-06-04 2020-06-04 Yes 2022-12-04 icosapent ethyl 227235 Vascepa HLS Therapeutics Inc. N/A 2019-12-30 2025-12-30 N/A 2027-12-30 idarucizumab 182503 Praxbind Boehringer Ingelheim (Canada) Ltd N/A 2016-04-29 2022-04-29 N/A 2024-04-29 idecabtagene vicleucel 244266 Abecma Celgene Inc. N/A 2021-05-26 2027-05-26 N/A 2029-05-26 idelalisib 172652 Zydelig Gilead Sciences Canada Inc symbicort steroid inhaler side effects.

N/A 2015-03-27 2021-03-27 N/A 2023-03-27 inclisiran sodium 243470 Leqvio Novartis Pharmaceuticals Canada Inc. N/A 2021-07-26 2027-07-26 N/A 2029-07-26 inotersen sodium 214274 Tegsedi Akcea symbicort steroid inhaler side effects Therapeutics Inc. N/A 2018-10-03 2024-10-03 N/A 2026-10-03 inotuzumab ozogamicin 204077 Besponsa Pfizer Canada Inc. N/A 2018-03-15 2024-03-15 N/A 2026-03-15 insulin degludec 198124 Tresiba Novo Nordisk Canada Inc.

Xultophy 2017-08-25 2023-08-25 Yes 2026-02-25 ioflupane (123I) 201481 Datscan symbicort steroid inhaler side effects GE Healthcare Canada Inc. N/A 2017-12-07 2023-12-07 N/A 2025-12-07 iron isomaltoside 1000 193890 Monoferric Pharmacosmos A/S N/A 2018-06-22 2024-06-22 N/A 2026-06-22 isatuximab 229245 Sarclisa Sanofi-Aventis Canada Inc. N/A 2020-04-29 2026-04-29 N/A 2028-04-29 isavuconazole (supplied as isavuconazonium sulfate) 208919 Cresemba Avir Pharma Inc. N/A 2018-12-19 2024-12-19 N/A 2026-12-19 ivabradine hydrochloride 166949 symbicort steroid inhaler side effects Lancora Servier Canada Inc.

N/A 2016-12-23 2022-12-23 Yes 2025-06-23 ivermectin 172733 Rosiver Galderma Canada Inc. N/A 2015-04-22 2021-04-22 N/A 2023-04-22 ixazomib (supplied as ixazomib citrate) 190498 Ninlaro Takeda Canada Inc. N/A 2016-08-04 2022-08-04 N/A symbicort steroid inhaler side effects 2024-08-04 ixekizumab 184993 Taltz Eli Lilly Canada Inc. N/A 2016-05-25 2022-05-25 Yes 2024-11-25 lanadelumab 213920 Takhzyro Takeda Canada Inc.

N/A 2018-09-19 2024-09-19 Yes 2027-03-19 larotrectinib (supplied as larotrectinib sulfate) 219998 Vitrakvi Bayer Inc. N/A 2019-07-10 2025-07-10 Yes 2028-01-10 latanoprostene bunod 211732 Vyzulta Bausch symbicort steroid inhaler side effects &. Lomb Incorporated N/A 2018-12-27 2024-12-27 N/A 2026-12-27 ledipasvir 173180 Harvoni Gilead Sciences Canada Inc. N/A 2014-10-15 2020-10-15 Yes 2023-04-15 lefamulin acetate 233292 Xenleta symbicort steroid inhaler side effects Sunovion Pharmaceuticals Canada Inc.

N/A 2020-07-10 2026-07-10 N/A 2028-07-10 lemborexant 231286 Dayvigo Eisai Limited N/A 2020-11-04 2026-11-04 N/A 2028-11-04 lenvatinib mesylate 180877 Lenvima Eisai Limited N/A 2015-12-22 2021-12-22 Yes 2024-06-22 letermovir 204165 Prevymis Merck Canada Inc. N/A 2017-11-01 2023-11-01 N/A 2025-11-01 levomilnacipran hydrochloride 167319 Fetzima Allergan Inc. N/A 2015-05-08 symbicort steroid inhaler side effects 2021-05-08 N/A 2023-05-08 lifitegrast 199810 Xiidra Novartis Pharmaceuticals Canada Inc. N/A 2017-12-22 2023-12-22 N/A 2025-12-22 linaclotide 161056 Constella Forest Laboratories Canada Inc.

N/A 2013-12-02 2019-12-02 N/A 2021-12-02 lixisenatide 193862 Adlyxine Sanofi-aventis Canada Inc. Soliqua 2017-05-25 2023-05-25 N/A 2025-05-25 lomitapide mesylate 160385 Juxtapid Aegerion symbicort steroid inhaler side effects Pharmaceuticals Canada Ltd. N/A 2014-02-04 2020-02-04 N/A 2022-02-04 lorlatinib 215733 Lorbrena Pfizer Canada ULC N/A 2019-02-22 2025-02-22 N/A 2027-02-22 lubiprostone 179333 Amitiza Sucampo Pharma Americas LLC N/A 2015-10-14 2021-10-14 N/A 2023-10-14 lumacaftor 181715 Orkambi Vertex Pharmaceuticals (Canada) Incorporated N/A 2016-01-26 2022-01-26 Yes 2024-07-26 luspatercept 236441 Reblozyl Celgene Inc. N/A 2020-09-25 2026-09-25 N/A 2028-09-25 lutetium177 Lu oxodotreotide 217184 Lutathera Advanced Accelerator Applications USA, Inc.

N/A 2019-01-09 2025-01-09 N/A symbicort steroid inhaler side effects 2027-01-09 macitentan 161372 Opsumit Janssen Inc. N/A 2013-11-06 2019-11-06 Yes 2022-05-06 mecasermin 235023 Increlex Ipsen Biopharmaceuticals Canada Inc. N/A 2020-12-17 2026-12-17 Yes 2029-06-17 mepolizumab 179850 Nucala GlaxoSmithKline Inc. N/A 2015-12-03 2021-12-03 symbicort steroid inhaler side effects Yes 2024-06-03 midostaurin 201101 Rydapt Novartis Pharmaceuticals Canada Inc.

N/A 2017-07-21 2023-07-21 Yes 2026-01-21 mifepristone 160063 Mifegymiso Linepharma International Limited N/A 2015-07-29 2021-07-29 Yes 2024-01-29 migalastat hydrochloride 196956 Galafold Amicus Therapeutics UK LTD N/A 2017-09-05 2023-09-05 N/A 2025-09-05 modified vaccinia symbicort (ankara-bavarian nordic) 144762 Imvamune Bavarian Nordic A/S N/A 2013-11-21 2019-11-21 N/A 2021-11-21 naloxegol oxalate 167790 Movantik Knight Therapeutics Inc. N/A 2015-06-02 2021-06-02 N/A 2023-06-02 necitumumab 193689 Portrazza Eli Lilly Canada Inc. N/A 2017-03-16 2023-03-16 symbicort steroid inhaler side effects N/A 2025-03-16 neisseria meningitidis serogroup A polysaccharide, neisseria meningitidis serogroup C polysaccharide, neisseria meningitidis serogroup W-135 polysaccharide, neisseria meningitidis serogroup Y polysaccharide, conjugated to tetanus toxoid carrier protein 154290 Nimenrix Pfizer Canada Inc. N/A 2013-03-05 2019-03-05 Yes 2021-09-05 neisseria meningitidis serogroup B recombinant lipoprotein 2086 (rLP2086) subfamily A and Neisseria meningitidis serogroup B recombinant lipoprotein 2086 (rLP2086) subfamily B 195550 Trumenba Pfizer Canada Inc.

N/A 2017-10-05 2023-10-05 Yes 2026-04-05 symbicort steroid inhaler side effects neratinib maleate 218224 Nerlynx Knight Therapeutics Inc. N/A 2019-07-16 2025-07-16 N/A 2027-07-16 netupitant 196495 Akynzeo Elvium Life Sciences N/A 2017-09-28 2023-09-28 N/A 2025-09-28 nintedanib (supplied as nintedanib esilate) 176043 Ofev Boehringer Ingelheim (Canada) Ltd N/A 2015-06-25 2021-06-25 N/A 2023-06-25 niraparib 216792 Zejula GlaxoSmithKline Inc. N/A 2019-06-27 2025-06-27 N/A 2027-06-27 nivolumab 180828 Opdivo Bristol-Myers-Squibb Canada N/A 2015-09-25 2021-09-25 Yes 2024-03-25 nusinersen 200070 Spinraza Biogen Canada Inc. N/A 2017-06-29 2023-06-29 Yes symbicort steroid inhaler side effects 2025-12-29 obeticholic acid 198418 Ocaliva Intercept Pharmaceuticals Inc.

N/A 2017-05-24 2023-05-24 N/A 2025-05-24 obiltoxaximab 230825 Anthim Elusys Therapeutics, Inc. N/A 2020-07-30 2026-07-30 N/A 2028-07-30 obinutuzumab 168227 Gazyva Hoffmann-La Roche Limited N/A 2014-11-25 2020-11-25 N/A 2022-11-25 ocrelizumab 198094 Ocrevus Hoffmann-La Roche Limited N/A 2017-08-14 2023-08-14 N/A 2025-08-14 olaparib 182823 Lynparza AstraZeneca Canada Inc. N/A 2016-04-29 2022-04-29 N/A 2024-04-29 olaratumab symbicort steroid inhaler side effects 203478 Lartruvo Eli Lilly Canada Inc. N/A 2017-11-23 2023-11-23 N/A 2025-11-23 ombitasvir, paritaprevir, dasabuvir sodium 174739 Holkira Pak Abbvie Corporation Technivie 2014-12-22 2020-12-22 N/A 2022-12-22 onasemnogene abeparvovec 239719 Zolgensma Novartis Pharmaceuticals Canada Inc.

N/A 2020-12-15 2026-12-15 Yes 2029-06-15 osimertinib mesylate 188171 Tagrisso AstraZeneca Canada Inc. N/A 2016-07-05 2022-07-05 symbicort steroid inhaler side effects N/A 2024-07-05 ospemifene 222001 Osphena Duchesnay Inc. N/A 2021-07-16 2027-07-16 N/A 2029-07-16 ozanimod (supplied as ozanimod hydrochloride) 232761 Zeposia Celgene Inc. N/A 2020-10-02 2026-10-02 N/A 2028-10-02 ozenoxacin 192925 Ozanex Ferrer Internacional, S.A.

N/A 2017-05-01 2023-05-01 symbicort steroid inhaler side effects Yes 2025-11-01 palbociclib 182048 Ibrance Pfizer Canada Inc. N/A 2016-03-16 2022-03-16 Yes 2024-09-16 pasireotide diaspartate 145005 Signifor Novartis Pharmaceuticals Canada Inc. Signifor Lar 2013-09-23 2019-09-23 N/A 2021-09-23 patiromer sorbitex calcium 210368 Veltassa Vifor Fresenius Medical Care Renal Pharma Ltd. N/A 2018-10-03 symbicort steroid inhaler side effects 2024-10-03 N/A 2026-10-03 patisiran (as patisiran sodium) 221896 Onpattro Alnylam Netherlands B.V.

N/A 2019-06-07 2025-06-07 N/A 2027-06-07 peginterferon beta-1a 166974 Plegridy Biogen Idec Canada Inc. N/A 2015-08-10 2021-08-10 N/A 2023-08-10 pembrolizumab 175884 symbicort steroid inhaler side effects Keytruda Merck Canada Inc. N/A 2015-05-19 2021-05-19 Yes 2023-11-19 peramivir 191280 Rapivab BioCryst Pharmaceuticals Inc. N/A 2017-01-05 2023-01-05 N/A 2025-01-05 perampanel 153747 Fycompa Eisai Limited N/A 2013-04-04 2019-04-04 Yes 2021-10-04 pitolisant hydrochloride 238175 Wakik Endo Ventures Ltd.

N/A 2021-05-25 2027-05-25 N/A 2029-05-25 plecanatide 215288 Trulance Bausch symbicort steroid inhaler side effects Health, Canada Inc. N/A 2019-10-10 2025-10-10 N/A 2027-10-10 polatuzumab vedotin 232303 Polivy Hoffmann-La Roche Limited N/A 2020-07-09 2026-07-09 N/A 2028-07-09 polidocanol 177359 Varithena Provensis Ltd. N/A 2015-08-04 2021-08-04 N/A 2023-08-04 pomalidomide 165891 Pomalyst Celgene Inc. N/A 2014-01-20 2020-01-20 symbicort steroid inhaler side effects Yes 2022-07-20 pralatrexate 207545 Folotyn Servier Canada Inc.

N/A 2018-10-26 2024-10-26 N/A 2026-10-26 pralsetinib 243731 Gavreto Hoffmann-La Roche Limited N/A 2021-06-30 2027-06-30 N/A 2029-06-30 prasterone 198822 Intrarosa Endoceutics Inc. N/A 2019-11-01 2025-11-01 N/A 2027-11-01 ponatinib hydrochloride 165121 Iclusig Ariad Pharmaceuticals Inc. N/A 2015-04-02 symbicort steroid inhaler side effects 2021-04-02 N/A 2023-04-02 ponesimod 239537 Ponvory Janssen Inc. N/A 2021-04-28 2027-04-28 N/A 2029-04-28 propiverine hydrochloride 188323 Mictoryl / Mictoryl Pediatric Duchesnay Inc.

N/A 2017-01-05 2023-01-05 Yes 2025-07-05 radium - 223 dichloride 161312 Xofigo Bayer Inc. N/A 2013-12-12 2019-12-12 symbicort steroid inhaler side effects N/A 2021-12-12 ramucirumab 176810 Cyramza Eli Lilly Canada Inc. N/A 2015-07-16 2021-07-16 N/A 2023-07-16 ravulizumab 217955 Ultomiris Alexion Pharma GmbH N/A 2019-08-28 2025-08-28 N/A 2027-08-28 recombinant haemagglutinin protein-strain A (H1N1) recombinant haemagglutinin protein-strain A (H3N2) recombinant haemagglutinin protein-strain B (Victoria) recombinant haemagglutinin protein-strain B (Yamagata) 235672 Supemtek Sanofi Pasteur Limited N/A 2021-01-14 2027-01-14 N/A 2029-01-14 recombinant human papillomasymbicort types 31, 33, 45, 52 and 58 170006 Gardasil 9 Merck Canada Inc. N/A 2015-02-05 2021-02-05 Yes 2023-08-05 recombinant neisseria meningitidis group B NHBA fusion protein, recombinant neisseria meningitidis group B NadA protein, recombinant neisseria meningitidis group B FHBP fusion protein, outer membrane vesicle (neisseria meningitidis group B NZ98/254 strain) 147275 Bexsero GlaxoSmithKline Inc.

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N/A 2018-01-25 2024-01-25 N/A 2026-01-25 triheptanoin 242196 Dojolvi Uagenyx Pharmaceutical Inc. N/A 2021-02-15 2027-02-15 Yes 2029-08-15 tucatinib 235295 Tukysa Seagen Inc. N/A 2020-06-05 2026-06-05 N/A 2028-06-05 turoctocog alfa 170796 Zonovate Novo Nordisk Canada Inc. N/A 2014-12-08 2020-12-08 Yes 2023-06-08 umeclidinium bromide 161585 Anoro Ellipta GlaxoSmithKline Inc. Incruse Ellipta 2013-12-23 2019-12-23 N/A 2021-12-23 upadacitinib 223734 Rinvoq AbbVie Corporation N/A 2019-12-23 2025-12-23 N/A 2027-12-23 varicella-zoster symbicort glycoprotein E (gE) 200244 Shingrix GlaxoSmithKline Inc.

N/A 2017-10-13 2023-10-13 N/A 2025-10-13 vedolizumab 169414 Entyvio Takeda Canada Inc. N/A 2015-01-29 2021-01-29 Yes 2023-07-29 velpatasvir 190521 Epclusa Gilead Sciences Canada Inc. Vosevi 2016-07-11 2022-07-11 Yes 2025-01-11 venetoclax 190761 Venclexta AbbVie Corporation N/A 2016-09-30 2022-09-30 N/A 2024-09-30 vernakalant hydrochloride 190817 Brinavess Cipher Pharmaceuticals Inc. N/A 2017-03-13 2023-03-13 N/A 2025-03-13 vilanterol trifenatate 157301 Breo Ellipta GlaxoSmithKline Inc. Anoro ElliptaTrelegy Ellipta 2013-07-03 2019-07-03 Yes 2022-01-03 vilazodone hydrochloride 176820 Viibryd Allergan Inc.

N/A 2015-07-16 2021-07-16 Yes 2024-01-16 von willebrand factor (recombinant) (vonicog alfa) 213188 Vonvendi Takeda Canada Inc. N/A 2019-01-10 2025-01-10 N/A 2027-01-10 vorapaxar sulfate 179320 Zontivity Toprol Acquisition LLC N/A 2016-05-13 2022-05-13 N/A 2024-05-13 voretigene neparvovec 233097 Luxturna Novartis Pharmaceuticals Canada Inc. N/A 2020-10-13 2026-10-13 Yes 2029-04-13 vortioxetine hydrobromide 159019 Trintellix Lundbeck Canada Inc. N/A 2014-10-22 2020-10-22 Yes 2023-04-22 voxilaprevir 202324 Vosevi Gilead Sciences Canada Inc. N/A 2017-08-16 2023-08-16 N/A 2025-08-16 zanubrutinib 242748 Brukinsa BeiGene Switzerland GmbH N/A 2021-03-01 2027-03-01 N/A 2029-03-01.

Symbicort nursing implications

€‹The families of four children who were tragically killed by a drunk and drugged driver are launching an annual http://practicalfireequipment.com/how-to-buy-cheap-cialis forgiveness day with the support of the NSW Government.Siblings Antony, Angelina and symbicort nursing implications Sienna Abdallah and their cousin Veronique Sakr were killed in February this year when an out-of-control ute mounted the footpath.The two families have taken the extraordinary step of forgiving the man behind the wheel as an important step in their grieving process.The families want i4give Day to be held every year on the anniversary of the deaths in memory of the children.In launching this day, a memorial service will be held on the eve of the anniversary, Sunday, 31 January 2021, which will be live streamed to the public.Daniel Abdallah said he wants i4give Day to become one when people can remember the four children but it may also help others who have suffered.“We still feel pain and sorrow everyday, but forgiveness has helped to get rid of the anger and bitterness. It’s helped us get through each day and make sure we are there for our other children,” said Mr Abdallah.Both families say this is about honouring their four little saints in heaven.“Our four children are now our four saints and this day is for them symbicort nursing implications. Forgiveness is the greatest gift you symbicort nursing implications can give yourself and others.

The more you practise the better you become at it and it allows you live peacefully and to heal.” Leila Abdallah said.“Christmas Eve is a very hard time for us as it is symbicort nursing implications also Angelina’s birthday. Even though it is tough, we’ll be celebrating Christmas for the rest of our kids.”Veronique’s mother Bridget Sakr, said “Christmas symbicort nursing implications can be a difficult time for many families. I hope people can reflect on what so tragically happened to our beautiful children to mend bridges with estranged family members and move forward, to symbicort nursing implications love each other in peace and harmony.

Life is too precious.”People across the state will be encouraged to reflect on events and relationships in their own lives and look to the example set by the Abdallah and Sakr families.Minister for Mental Health Bronnie Taylor said that while grieving is a normal part of life, when a tragedy such as this occurs the impact on the family is profound.“The grief experienced can take many forms and there symbicort nursing implications is no set timeline. For some people a psychologist symbicort nursing implications or grief and trauma therapist may be of assistance and the need for this may occur months or years after the event,” Mrs Taylor said.“For some people where the loss has occurred through trauma, forgiveness may play a healing role as part of the grieving process.“This day is about honouring Antony, Angelina, Sienna and Veronique. Their families have shown amazing strength through symbicort nursing implications such a terrible tragedy.”A website i4give.com will also be launched where people will be directed to links dealing with grief and trauma counselling..

€‹The families of four children who were tragically killed by a drunk and drugged driver are launching an annual forgiveness day with the support of the NSW Government.Siblings Antony, Angelina and Sienna Abdallah and their cousin Veronique Sakr were killed in February this year when an out-of-control ute mounted the footpath.The two families have find this taken the extraordinary step of forgiving the man behind the wheel as an important step in their grieving process.The families want i4give Day to can i buy symbicort over the counter be held every year on the anniversary of the deaths in memory of the children.In launching this day, a memorial service will be held on the eve of the anniversary, Sunday, 31 January 2021, which will be live streamed to the public.Daniel Abdallah said he wants i4give Day to become one when people can remember the four children but it may also help others who have suffered.“We still feel pain and sorrow everyday, but forgiveness has helped to get rid of the anger and bitterness. It’s helped us get through each day and make can i buy symbicort over the counter sure we are there for our other children,” said Mr Abdallah.Both families say this is about honouring their four little saints in heaven.“Our four children are now our four saints and this day is for them. Forgiveness is the greatest gift you can give can i buy symbicort over the counter yourself and others. The more you practise the better you become at it and it allows you live peacefully and to heal.” Leila Abdallah said.“Christmas can i buy symbicort over the counter Eve is a very hard time for us as it is also Angelina’s birthday. Even though it is can i buy symbicort over the counter tough, we’ll be celebrating Christmas for the rest of our kids.”Veronique’s mother Bridget Sakr, said “Christmas can be a difficult time for many families.

I hope people can reflect on what so tragically happened can i buy symbicort over the counter to our beautiful children to mend bridges with estranged family members and move forward, to love each other in peace and harmony. Life is too precious.”People across the state will be encouraged to reflect on events and relationships in their own lives and look to the example set by the Abdallah and Sakr families.Minister for Mental can i buy symbicort over the counter Health Bronnie Taylor said that while grieving is a normal part of life, when a tragedy such as this occurs the impact on the family is profound.“The grief experienced can take many forms and there is no set timeline. For some people a psychologist or grief and trauma therapist may be of assistance and the need for this may occur months or years after the event,” Mrs Taylor said.“For some people where the loss has occurred through trauma, forgiveness may play a healing role as part of the grieving process.“This day is about honouring Antony, Angelina, can i buy symbicort over the counter Sienna and Veronique. Their families can i buy symbicort over the counter have shown amazing strength through such a terrible tragedy.”A website i4give.com will also be launched where people will be directed to links dealing with grief and trauma counselling..

Symbicort dizziness

In response to the anti inflammatory drugs symbicort, members of http://www.gs-forellstrasse.soltest.de/cheap-generic-levitra-online/ the Rapid Deployment treatment Collaborative (or RaDVaC)—a group composed of scientists and their friends or colleagues—have been self-administering an untested symbicort dizziness treatment for anti-inflammatories (the symbicort that causes anti inflammatory drugs). The RaDVaC scientists describe their project as aiming “to reduce risk of harm from anti-inflammatories, minimally until there is at least one effective commercial treatment widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions. Self-experimentation has a symbicort dizziness fascinating history. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the study team as participants.

These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants. Some Nobel symbicort dizziness Prize–winning work by scientists was based on self-experimentation that initially was seen as crazy. For instance, in 1984, Barry Marshall swallowed bacteria to prove that they caused gastritis and peptic ulcers. Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart.

Perhaps surprisingly, self-experimentation symbicort dizziness was once considered an ethical safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies. However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only is self-experimentation legally and ethically complex, but protections like independent review and informed consent, which are now required by research regulations, may be a better way to symbicort dizziness protect research participants.

Existing regulations for research were not designed to address self-experimentation. Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people. In addition, symbicort dizziness the U.S. Common Rule governs federally funded research, and RaDVaC is not using any federal funding.

However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies of immune responses involving self-experimentation are planned in symbicort dizziness George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, which would provide some oversight of this self-experimentation. If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight. The U.S.

Food and Drug Administration has similar power to regulate research, and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if symbicort dizziness they are not distributed for profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key anti-inflammatories proteins—and therefore may fall under the FDA’s jurisdiction. While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people were symbicort dizziness harmed by taking this treatment, they could also sue RaDVaC, but the disclaimers in the white paper are carefully designed to avoid liability.

Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort. If RaDVaC intends to produce generalizable knowledge about this treatment, unsystematic self-experimentation is unlikely to produce useful information. For example, self-experimentation can lead to biased results if researchers symbicort dizziness overestimate the chance that the treatment works, or fail to report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo.

Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this treatment based on these expert’s recommendations, which could lead to two potential misconceptions. First, people taking the treatment might overestimate the likelihood that they are symbicort dizziness protected from anti-inflammatories and change their behavior. If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others. A second misconception is the idea that this is research that could benefit others.

The same data analyst seemed to believe this when he added “my continued existence through this symbicort will be a useful data set.” Yet the RaDVaC project could not produce useful symbicort dizziness data in the same way as standard, well-designed treatment trials, for example, because it is unclear whether individuals receiving the treatment are thoroughly evaluated or monitored, and there does not appear to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege. Senior scientists benefit from many layers symbicort dizziness of privilege. Investment in their education, expertise in specialized areas, and access to information or materials.

Arguably, these privileges come with a responsibility to use expertise for the benefit of society. If the RaDVaC symbicort dizziness treatment is potentially beneficial, then it is tragic not to test it in a rigorously designed study. Indeed, uncontrolled self-experimentation is part of a larger problem in the anti inflammatory drugs symbicort. Panic about the symbicort has led to the widespread use of interventions outside of well-designed clinical trials.

Without such trials, we symbicort dizziness remain in the dark about which interventions offer net benefits or net harms. Insofar as the scientists involved have expertise in treatment research, they should either reform the RaDVaC project or lend their expertise to serious projects. On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful. Earlier this symbicort dizziness week, Steven Salzberg, a computational biologist, called for experimental anti inflammatory drugs treatments to be rolled out before the results of phase III testing.

An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately. Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research. Their time might be better spent on projects in these fields, which will still be important when this symbicort is finally symbicort dizziness over. Rather than trying everything but the kitchen sink against anti inflammatory drugs, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for anti inflammatory drugs.

RaDVaC’s scientists should be encouraged to collaborate on systematic anti inflammatory drugs treatment testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color. The stalagmites and stalactites of Goikoetxe Cave are symbicort dizziness not just the usual white. Many range from honey to deep red. New research shows that these formations, known generally as speleothems, get their red color from organic compounds leached from soil and transported by water.

Scientists suggest, in an article published online in April in Quaternary International, that Goikoetxe Cave's speleothems record environmental conditions symbicort dizziness such as rainfall.The wildfire season is off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage. But that’s just one consequence of global warming. It’s also leading to flooding, torrential rainstorms and heat-related deaths symbicort dizziness.

In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often. I vividly remember a patient who came in late for her appointment during a July symbicort dizziness heat wave. When I walked in, she said, “I’m so sorry I’m late, I was up all night walking my grandbaby around the train station.” Without air conditioning at home, the child was sweating through her clothes in the heat of the night, putting her at risk for dehydration.

July 2019 was the hottest July on record. September 2019 was the hottest on record symbicort dizziness. January 2020 was the hottest on record. May 2020 was the hottest on record.

This is symbicort dizziness not a coincidence. It is a pattern. Carbon dioxide, an important greenhouse gas contributing to global warming, has increased by 9 percent since 2005 and by 31 percent since 1950. A U.N symbicort dizziness.

Intergovernmental Panel on Climate Change special report pointed out that the world has already warmed about one degree Celsius from pre-industrial levels. It stressed the urgency to act to limit warming to 1.5 degrees, and that a two-degree increase will lead to unprecedented extreme heat, water scarcity and food shortages around the symbicort dizziness globe. Heat affects every part of our body. It can lead to heat exhaustion, heat stroke, anxiety, impaired cognitive function and even premature death from heart and lung disease.

Across the country, the health concerns of the climate crisis are increasingly being recognized, pushing thousands of medical providers—doctors, nurses, pharmacists, therapists, medical symbicort dizziness students—to become advocates for change. In my own practice, I explain to patients how the climate crisis affects their health. For example, apart from contributing to global warming, rising carbon dioxide levels increase the amount of pollen that plants produce as a consequence of higher rates of photosynthesis. This rise in pollen levels can lead to worsening symbicort dizziness allergy symptoms.

Another example is fine particulate matter (known as PM2.5) associated with air pollution, much of it linked to the burning of fossil fuels that help drive the warming. When we breathe in these particles, they travel down the airway and settle in the tiny air sacs called alveoli of the lungs, causing inflammation and potentially worsening asthma symptoms. The explanations are symbicort dizziness simple, but the health risks are widespread and complex. Ground-level ozone pollution, which is worse in hotter weather, can also harm people with asthma and other respiratory diseases.

And that harm falls disproportionately on the poor. Wealthier people living in North America have a per capita carbon footprint that is 25 percent higher than those of lower-income residents, with some affluent suburbs producing emissions symbicort dizziness 15 times higher than nearby neighborhoods. These carbon emissions contribute to global warming, and the subsequent health consequences are felt far beyond the neighborhood that produces them. Older adults, children, low-income communities and communities of color are less resilient on average to the health impacts of climate change.

The climate symbicort dizziness crisis is thus leading to a disproportionate public health crisis—and worse, it is a threat multiplier. At a time when many Americans are economically challenged, continued heat waves and the higher energy bills they trigger threaten access to water and energy security. The economic benefits of a low-carbon economy are clear. Estimates suggest that without climate investments, the United States will face economic damage from climate change equivalent to 1–3 percent of GDP per year by 2100 symbicort dizziness.

The majority of Americans think global warming is happening. The climate crisis has unfairly been labeled as political, when in fact, people recognize that something needs to be done about it. Even for those who are seemingly unaffected, there is increasing global recognition that the safeguards of living in a protected community and affording expert medical care will eventually fail if global warming symbicort dizziness continues unchecked. Unfortunately, there will be no treatment in six months or a year for the climate crisis.

The only treatment is collective climate action in the present. Climate action is required of our elected leaders, and we must mandate it of ourselves symbicort dizziness. It can be as simple as educating family and friends, while making sustainable shopping and traveling choices. It includes eating less meat, unplugging electronics and raising a voice against the fossil fuel industry.

With a rise in demand for absentee ballots for the election this November, it is crucial to symbicort dizziness request mail-in ballots right away to make sure our voices are heard. The United States is the second largest emitter of greenhouse gases, and we must vote for green policy. Legislative action and policy change work, as evidenced by the Clean Air Act and its subsequent amendments, which are projected to save 230,000 lives in 2020. The climate crisis is a public health issue, symbicort dizziness and we must start healing the planet in order to heal each other.

Fighting against the climate crisis is one of the most patriotic things we can do right now. It will protect our health and the health of our neighbors across the country and the globe, and will allow all of us to live on this planet, the only home we have..

In response to http://www.gs-forellstrasse.soltest.de/cheap-generic-levitra-online/ the anti inflammatory drugs symbicort, members of can i buy symbicort over the counter the Rapid Deployment treatment Collaborative (or RaDVaC)—a group composed of scientists and their friends or colleagues—have been self-administering an untested treatment for anti-inflammatories (the symbicort that causes anti inflammatory drugs). The RaDVaC scientists describe their project as aiming “to reduce risk of harm from anti-inflammatories, minimally until there is at least one effective commercial treatment widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions. Self-experimentation has a fascinating can i buy symbicort over the counter history. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the study team as participants. These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants.

Some Nobel can i buy symbicort over the counter Prize–winning work by scientists was based on self-experimentation that initially was seen as crazy. For instance, in 1984, Barry Marshall swallowed bacteria to prove that they caused gastritis and peptic ulcers. Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart. Perhaps surprisingly, self-experimentation was once considered an ethical can i buy symbicort over the counter safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies.

However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only is self-experimentation legally and ethically complex, but protections like independent review and informed consent, which are now required by research regulations, may be a better way to can i buy symbicort over the counter protect research participants. Existing regulations for research were not designed to address self-experimentation. Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people. In addition, the U.S can i buy symbicort over the counter.

Common Rule governs federally funded research, and RaDVaC is not using any federal funding. However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies of immune responses involving self-experimentation can i buy symbicort over the counter are planned in George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, which would provide some oversight of this self-experimentation. If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight. The U.S.

Food and Drug Administration has similar power to regulate research, and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if they are not distributed for can i buy symbicort over the counter profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key anti-inflammatories proteins—and therefore may fall under the FDA’s jurisdiction. While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people can i buy symbicort over the counter were harmed by taking this treatment, they could also sue RaDVaC, but the disclaimers in the white paper are carefully designed to avoid liability. Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort.

If RaDVaC intends to produce generalizable knowledge about this treatment, unsystematic self-experimentation is unlikely to produce useful information. For example, self-experimentation can lead to biased results if researchers overestimate the chance that the treatment works, or fail to can i buy symbicort over the counter report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo. Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this treatment based on these expert’s recommendations, which could lead to two potential misconceptions. First, people taking the treatment might overestimate the likelihood that they can i buy symbicort over the counter are protected from anti-inflammatories and change their behavior.

If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others. A second misconception is the idea that this is research that could benefit others. The same data analyst seemed to believe this when he added “my continued existence through this symbicort will be a useful data set.” Yet the RaDVaC project could not produce useful data in the same way as standard, well-designed treatment trials, for example, because can i buy symbicort over the counter it is unclear whether individuals receiving the treatment are thoroughly evaluated or monitored, and there does not appear to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege. Senior scientists benefit from many layers of privilege can i buy symbicort over the counter.

Investment in their education, expertise in specialized areas, and access to information or materials. Arguably, these privileges come with a responsibility to use expertise for the benefit of society. If the RaDVaC treatment can i buy symbicort over the counter is potentially beneficial, then it is tragic not to test it in a rigorously designed study. Indeed, uncontrolled self-experimentation is part of a larger problem in the anti inflammatory drugs symbicort. Panic about the symbicort has led to the widespread use of interventions outside of well-designed clinical trials.

Without such trials, we remain can i buy symbicort over the counter in the dark about which interventions offer net benefits or net harms. Insofar as the scientists involved have expertise in treatment research, they should either reform the RaDVaC project or lend their expertise to serious projects. On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful. Earlier this can i buy symbicort over the counter week, Steven Salzberg, a computational biologist, called for experimental anti inflammatory drugs treatments to be rolled out before the results of phase III testing. An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately.

Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research. Their time might be better spent on projects in these fields, which can i buy symbicort over the counter will still be important when this symbicort is finally over. Rather than trying everything but the kitchen sink against anti inflammatory drugs, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for anti inflammatory drugs. RaDVaC’s scientists should be encouraged to collaborate on systematic anti inflammatory drugs treatment testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color. The stalagmites and stalactites of Goikoetxe Cave are not just the usual can i buy symbicort over the counter white.

Many range from honey to deep red. New research shows that these formations, known generally as speleothems, get their red color from organic compounds leached from soil and transported by water. Scientists suggest, in an article published online in April in Quaternary International, that Goikoetxe Cave's speleothems record environmental conditions such as rainfall.The wildfire season is can i buy symbicort over the counter off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage. But that’s just one consequence of global warming.

It’s also leading to flooding, torrential can i buy symbicort over the counter rainstorms and heat-related deaths. In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often. I vividly can i buy symbicort over the counter remember a patient who came in late for her appointment during a July heat wave. When I walked in, she said, “I’m so sorry I’m late, I was up all night walking my grandbaby around the train station.” Without air conditioning at home, the child was sweating through her clothes in the heat of the night, putting her at risk for dehydration.

July 2019 was the hottest July on record. September 2019 was can i buy symbicort over the counter the hottest on record. January 2020 was the hottest on record. May 2020 was the hottest on record. This is not can i buy symbicort over the counter a coincidence.

It is a pattern. Carbon dioxide, an important greenhouse gas contributing to global warming, has increased by 9 percent since 2005 and by 31 percent since 1950. A U.N can i buy symbicort over the counter. Intergovernmental Panel on Climate Change special report pointed out that the world has already warmed about one degree Celsius from pre-industrial levels. It stressed the urgency to act can i buy symbicort over the counter to limit warming to 1.5 degrees, and that a two-degree increase will lead to unprecedented extreme heat, water scarcity and food shortages around the globe.

Heat affects every part of our body. It can lead to heat exhaustion, heat stroke, anxiety, impaired cognitive function and even premature death from heart and lung disease. Across the country, the health can i buy symbicort over the counter concerns of the climate crisis are increasingly being recognized, pushing thousands of medical providers—doctors, nurses, pharmacists, therapists, medical students—to become advocates for change. In my own practice, I explain to patients how the climate crisis affects their health. For example, apart from contributing to global warming, rising carbon dioxide levels increase the amount of pollen that plants produce as a consequence of higher rates of photosynthesis.

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Fighting against the climate crisis is one of the most patriotic things we can do right now. It will protect our health and the health of our neighbors across the country and the globe, and will allow all of us to live on this planet, the only home we have..