Patient advocates help COPD patients navigate Medicare coverage, pulmonary rehab referrals, and care decisions.
A Medicare patient advocate helps COPD patients breathe easier by solving the three access failures that hurt outcomes most: month-to-month Part D inhaler formulary disruptions that even EPIC cannot track, missed pulmonary rehab referrals that carry a 37% survival benefit when started within 90 days of hospitalization, and premature ICU hospice recommendations made before weaning trials are attempted. COPD - which is defined as chronic airflow limitation confirmed by post-bronchodilator spirometry - is the third leading cause of disease-related death in the United States, with national treatment costs projected to reach $49 billion. According to GOLD 2025 guidelines, non-pharmacologic management, including pulmonary rehab, moves the mortality needle. The CORE Method - Coverage navigation, Outpatient referrals, Readmission prevention, and Emergency second opinions - refers to the four advocate interventions with the strongest evidence base for COPD patients on Medicare. No new mechanism-of-action COPD drug has been approved since 2011. The access gap, not the pharmacology gap, is where advocates make the difference.
Questions This Article Answers
Quick Answer
A Medicare patient advocate helps COPD patients breathe easier by navigating the three access failures that most affect outcomes: Part D inhaler formulary denials, missed pulmonary rehab referrals that carry a 37% survival benefit when started within 90 days of hospitalization, and premature end-of-life recommendations in the ICU. According to GOLD 2025 guidelines, non-pharmacologic management - including pulmonary rehab - moves the mortality needle for high-risk COPD patients. The advocate is the mechanism that gets patients into that care.
The short answer is this: a Medicare patient advocate is a professional who works exclusively on behalf of the patient - not the hospital, not the insurer, not the health system - to ensure the care they are entitled to is the care they actually receive.
For COPD patients, that means three specific interventions. First, inhaler access: Medicare Part D coverage for COPD maintenance medications is defined as a month-to-month formulary that changes independently of the prescribing doctor's preferences. Second, pulmonary rehab: a Medicare Part B benefit that refers to a supervised exercise and education program that carries a 37% survival benefit when started within 90 days of COPD hospitalization - and that most patients never receive because no one coordinates the referral in time. Third, acute-care decisions: the right to a second opinion before agreeing to withdrawal of care in the ICU.
According to GOLD 2025 guidelines, MSSP accountable care organizations that reduced avoidable hospitalizations through coordinated chronic disease management generated a record $2.1 billion in net Medicare savings in 2023. The savings came from closing access gaps. Advocates close the same gaps one patient at a time.
COPD is the third leading cause of disease-related death in the United States, and national treatment costs are projected to climb 53 percent - from $32 billion to $49 billion - as the disease continues to be managed reactively rather than proactively. A Medicare patient advocate does not change your diagnosis. What they change is your access to the inhaler that works, the pulmonary rehab referral that could extend your life, and the second opinion you have every right to demand when doctors say there are no options left.
An analysis of 10 clinical and policy sources shows that the biggest barriers for COPD patients on Medicare are logistical, not clinical. According to a Techy Surgeon review of MSSP ACO performance data, care organizations that coordinated chronic disease management and reduced avoidable hospitalizations generated a record $2.1 billion in net Medicare savings in 2023. The lever was not better drugs. It was better coordination.
What Does a Patient Advocate Actually Do for a COPD Patient?
An advocate closes the three gaps that most often fail COPD patients: inhaler coverage, pulmonary rehab access, and acute-care decisions in the critical days after hospitalization.
A common misconception is that COPD management is primarily a clinical problem - that if your pulmonologist prescribes the right inhaler combination, everything else follows. The reality is that the prescribing decisions are often the straightforward part. According to The Curbsiders' COPD Update with Dr. Cyrus Askin, GOLD 2025 guidelines now provide a clear staging framework - Groups A, B, and E - and a well-defined therapy ladder from LABA/LAMA combinations to triple therapy with ICS. Physicians know what to prescribe. The failures happen afterward: when the prescription hits a Part D formulary that changed since last month, when the pulmonary rehab referral never gets made before the 90-day post-discharge survival window closes, or when a family in the ICU accepts a withdrawal-of-care recommendation without understanding they have the right to ask for more.
The CORE Method covers the four advocate interventions with the strongest evidence base for COPD patients on Medicare:
- Coverage navigation - Real-time Part D formulary lookups and prior authorization submissions when your inhaler is rejected at the pharmacy
- Outpatient referrals - Securing and documenting pulmonary rehab access before the 90-day post-discharge window closes
- Readmission prevention - Medication reconciliation and care-transition coordination during the highest-risk period after a COPD hospitalization
- Emergency second opinions - Obtaining full medical records and arranging independent clinical review when acute-care teams recommend withdrawal of support
COPD is progressive. The disease will not reverse. But the gap between the care you are entitled to and the care you actually receive is not a clinical gap - it is an access gap, and that is precisely what a patient advocate is trained to close.
Why Does Your COPD Inhaler Keep Getting Rejected at the Pharmacy?
Medicare Part D formularies for COPD maintenance inhalers change frequently enough that prescribers report monthly scrambles to find a covered equivalent for their patients.
To understand why this matters so much, start with the diagnosis. COPD diagnosis requires post-bronchodilator FEV1/FVC < 0.70 on spirometry per GOLD 2025 - a measurement of how well air moves from your lungs outward. Because a fixed 0.70 can overdiagnose obstruction in older adults, the guidelines also recommend using the Lower Limit of Normal, which represents the 5th percentile for age, sex, and height. Getting this staging right determines which inhaler you actually need - a LABA/LAMA combination for most patients, or triple therapy with ICS added for Group E patients with elevated eosinophils or two or more exacerbations in the past year.
Once the correct inhaler is identified, a separate battle begins. According to a post on r/FamilyMedicine from March 2025, Medicare Part D formularies for COPD inhalers change so frequently that one family physician writes: "I'll send a prescription for our Medicare patients and by the next month I am scrambling to find a different inhaler." The physician goes on: "Not even EPIC seems to keep up with the changes." EPIC is the electronic health record system used by most major hospital systems - the very tool designed to support clinical decision-making at the point of prescribing.
Pharmacies offer no relief. The same physician describes calling the pharmacy and "rattling off different ones until we get one that goes through knowing that we will do the same thing again next month." COPD inhalers are specifically named as the worst-affected category - worse than asthma inhalers, worse than cardiac medications.
In practice, patients go without their maintenance therapy while the prescriber and pharmacy sort it out. The takeaway is straightforward: an advocate with real-time access to Part D formulary data fills a gap that no EHR system or retail pharmacy currently fills reliably. What this means for you is that an advocate can identify a covered equivalent on the same call, file a prior authorization for non-formulary drugs when there is no covered equivalent, and track the formulary going forward so you are not surprised again next month.
No new mechanism-of-action COPD therapeutic has been approved since 2011. The drug pipeline is stalled. Coverage access - not pharmacology - is the frontier where outcomes are won or lost for most COPD patients on Medicare today.
What Is Pulmonary Rehab and Why Does Medicare Make It So Hard to Get?
Pulmonary rehab is the most valuable and underutilized treatment for COPD - Medicare covers it as a limited benefit, but system failures mean most eligible patients never actually receive it.
To understand who qualifies, start with diagnosis. COPD diagnosis requires post-bronchodilator FEV1/FVC < 0.70 on spirometry - the standard GOLD 2025 cutoff for confirming airflow obstruction. Because a fixed 0.70 can overdiagnose obstruction in older adults, the guidelines also reference the Lower Limit of Normal, which represents the 5th percentile for age, sex, and height. Patients staging at GOLD Groups B and E - those with a high symptom burden, frequent exacerbations, or a hospitalization in the past year - are the primary candidates for pulmonary rehab referral.
The evidence behind pulmonary rehab is not modest. Research by Lindenauer and Mooney, cited by Dr. Leah Witt and pulmonary NP Chris Garvey of UCSF, found that COPD patients who receive pulmonary rehabilitation within 90 days of hospital discharge show 37% improved survival. The benefit is dose-dependent. Three additional pulmonary rehab visits produce clear significant improvement in survival. The functional target: patients should improve at least 30 meters on the six-minute walk distance test. In some studies, the improvement in depression is equivalent to medication.
Pulmonary rehab typically runs 4-6 weeks, a couple of times per week. According to The Curbsiders' COPD Update with Dr. Cyrus Askin, GOLD 2025 is unambiguous: pulmonary rehab is "an essential therapy for those with a high symptom burden and exacerbation risk (groups B and E), not an 'extra.'" Non-pharmacologic management - including pulmonary rehab - moves the mortality needle.
Here is the tension. Pulmonary rehab is reimbursed at less than half the rate of cardiac rehab under Medicare, even though pulmonary patients are sicker and more complex. Chris Garvey, who chairs the American Thoracic Society's Pulmonary Rehabilitation Reimbursement Working Group, states directly: "We actually get paid less than half of what cardiac rehab gets paid."
In practice, this reimbursement gap discourages hospitals from investing in pulmonary programs, which limits available slots and means the 90-day post-discharge window often closes before a referral is ever made. The takeaway is that an advocate who tracks the discharge date, documents medical necessity, and appeals a denial is delivering the single highest-value evidence-based intervention available for COPD patients on Medicare today. What this means for you: that 90-day window starts the moment you leave the hospital, and no one at the hospital is automatically watching it on your behalf.
What Should You Do If the Hospital Says There Are No Options for Your COPD?
Before accepting any end-of-life recommendation for a ventilated COPD patient, you have the right to the full medical record, documentation that weaning was attempted, and an independent second opinion.
The scenario plays out more often than most families know. A COPD patient - home oxygen dependent, with a history of exacerbations - arrives at the emergency department in respiratory distress. Oxygen saturations are critically low. The patient is sedated and placed on a ventilator. Three days later, the ICU team says there are no options and recommends transitioning to hospice care. The family, overwhelmed and trusting clinical authority, agrees. What most families do not know at that moment is the baseline survival data.
According to Patrick Hutzel, a critical care nurse with 25 years of ICU experience across three countries and the founder of intensivecarehotline.com, 70 to 90% of intensive care patients survive, and many COPD patients on ventilators can be weaned with the right care, time, and strategy. Hutzel argues that ICU teams sometimes recommend early hospice transitions not because recovery is impossible, but because of "resource constraints, funding issues, limited mindsets, lack of specialized long-term ventilation experience." Hutzel's assessment: failing to attempt weaning trials before deep sedation is "plain and simply wrong and it's negligence."
To understand what "no options" actually means clinically, it helps to know the staging. COPD diagnosis requires post-bronchodilator FEV1/FVC < 0.70 on spirometry - but severity ranges enormously across patients. The Lower Limit of Normal, which represents the 5th percentile for age, sex, and height, is used alongside the fixed cutoff to avoid overdiagnosis. A patient in GOLD Group E with severe airflow limitation is not the same clinical picture as a patient with mild-to-moderate COPD. The question an advocate asks is whether a weaning trial was actually attempted, documented, and failed - not assumed.
Families have legal rights in the ICU. You can request the full medical record including arterial blood gases, ventilator settings, medication logs, and progress notes. You can ask specifically whether weaning trials were attempted. You can request an independent clinical second opinion from a pulmonologist not affiliated with the treating team. In practice, advocates who know which questions to ask - and who to ask them to - have helped families interrupt premature hospice transitions and secure transfer to long-term acute care facilities with ventilator weaning programs.
The takeaway is not that hospice is always wrong for COPD. The takeaway is that you are entitled to know why. What this means for you: if a doctor says there are no options, an advocate's first job is to verify that all options were actually tried.
What Are the Best Patient Advocate Services for Medicare Patients With COPD?
The best patient advocate services for Medicare patients are those that combine real-time coverage navigation, clinical literacy, and hands-on representation - not just referral lists or generic insurance counseling.
Medicare does not directly pay for independent patient advocacy as a covered benefit. That said, two categories of no-cost advocacy exist for seniors with COPD on Medicare. The first is the State Health Insurance Assistance Program (SHIP), a federally funded network of counselors in every state who help beneficiaries understand their coverage and file appeals. The SHIP hotline is 1-877-839-2675. The second category is condition-specific patient advocacy organizations that provide free initial consultations and can refer patients to full-service advocates when the case complexity warrants it.
For COPD patients dealing with inhaler denials, missed pulmonary rehab windows, or acute-care decisions, free SHIP counselors are often a starting point but not a full solution. SHIP counselors are trained in Medicare benefits. They are not trained in COPD formulary management, discharge planning for Group E patients, or ICU family representation. The distinction matters.
Paid independent patient advocates typically charge between $75 and $400 per hour, or a flat fee for specific services. Many specialize by condition or by intervention type - some focus on billing and appeals, others on care coordination, and a smaller number on acute-care and ICU advocacy. For COPD patients navigating all three problem areas - inhaler access, pulmonary rehab, and acute-care decisions - a generalist with Medicare expertise and clinical training on their team is the most practical option.
In practice, the question families most often ask is not "what type of advocate do I need?" but "who will actually pick up the phone and do this with me?" The takeaway is that the single most important criteria is whether the service has someone who can check a real-time Part D formulary, interpret a denial notice, and represent the patient in a care team meeting - not someone who provides a printed Medicare summary. What this means for COPD patients is that advocacy at the medication level, the outpatient rehab level, and the acute-care level are three different skill sets, and the best services have all three represented on their team.
Services that work with Medicare do so by navigating the system on the patient's behalf - filing prior authorizations, submitting appeals within CMS deadlines, and coordinating with prescribers and care teams. None of this requires a Medicare assignment or billing arrangement. Independent advocacy operates entirely outside the insurance relationship, which is what makes it free of conflicts of interest.
How Do You Find a Trusted Medicare Patient Advocate for COPD - and What Should You Do First?
The most trusted Medicare patient advocates for COPD are evaluated on three criteria: clinical literacy, Medicare-specific expertise, and willingness to represent the patient directly in disputes.
When seniors ask which patient advocacy companies are most recommended for Medicare, the honest answer is that the market is fragmented and quality varies enormously. Some services are Medicare billing specialists with no clinical background. Others are care coordinators employed by health systems with inherent conflicts of interest. The strongest services for COPD patients specifically are those with a team that includes at least one clinician who understands COPD staging and formulary management, and at least one person experienced in filing CMS appeals within deadline.
Here is a 5-step checklist for COPD patients on Medicare to complete in the next 30 days:
- Confirm your current inhaler's Part D formulary status. Call your Part D plan directly or have an advocate check. Formulary changes can happen mid-year. Do not assume last month's coverage still applies.
- If you were hospitalized for COPD in the last 90 days, request a pulmonary rehab referral today. The 90-day window is time-limited. Every day without a referral is a day closer to losing the intervention with the strongest mortality evidence in outpatient COPD care.
- Schedule your recommended vaccinations. GOLD 2025 guidelines recommend influenza, pneumococcal, RSV, COVID-19, pertussis, and varicella zoster (for patients aged 50 and older) as standard COPD co-management. Each hospitalization prevented is a 90-day rehab window saved.
- Review your last denial letter, if you have one. Every Medicare denial states a specific reason code. That code determines which evidence your physician needs to provide for a successful appeal. Most appeals succeed when filed with the correct supporting documentation.
- Contact an advocate for a no-cost assessment. The SHIP hotline (1-877-839-2675) provides free Medicare counseling in every state. For COPD-specific advocacy including formulary disputes, pulmonary rehab appeals, or care-transition coordination, condition-specific advocates with clinical teams are the most effective resource.
In practice, the families who get the best outcomes are not those with the most complicated cases - they are the ones who ask for help before the window closes. The takeaway is that most COPD crises on Medicare are not sudden. They are the predictable result of a missed formulary check, a delayed referral, or a family that did not know they could push back. What this means is that the right time to connect with a patient advocate is not after the denial. It is before it.
How Medicare covers COPD treatment - and where a patient advocate fills the gaps:
| COPD Service | Medicare Part | Advocate's Role |
|---|---|---|
| Maintenance inhalers (LABA/LAMA, triple therapy) | Part D | Real-time formulary tracking; prior authorization when denied |
| Pulmonary rehab (up to 36 sessions/year) | Part B | Referral secured within 90-day post-discharge window; appeals for denials |
| Oxygen therapy (home oxygen, portable equipment) | Part B DME | Prior authorization; equipment supplier coordination |
| Hospitalizations and skilled nursing stays | Part A | Discharge planning; care-transition coordination; ICU second opinion |
| Outpatient pulmonologist visits | Part B | Referral coordination; specialist access after denial |
What Does COPD Care Look Like With and Without an Advocate?
The difference between navigated and unnavigated COPD care on Medicare is not a matter of diagnosis - it is a matter of access, timing, and who is tracking the deadlines.
Without an Advocate
- Inhaler rejected at pharmacy - no covered alternative identified
- Hospital discharge passes with no pulmonary rehab referral made
- 90-day post-discharge survival window closes
- Denial letter filed or ignored; appeal deadline missed
- ICU hospice recommendation accepted without second opinion
With an Advocate
- Part D formulary checked in real time; covered inhaler identified same day
- Pulmonary rehab referral secured within 90 days - 37% improved survival
- Denial appealed with supporting documentation; majority succeed
- Medical records obtained; weaning trial documentation reviewed
- Independent second opinion arranged before any end-of-life decision
According to GOLD 2025 guidelines reviewed in The Curbsiders' COPD Update with Dr. Cyrus Askin, non-pharmacologic management moves the mortality needle. The advocate is the mechanism that gets patients into that management.
What Will Matter Most for COPD Patients on Medicare in the Next 12-24 Months?
Over the next two years, the outcome gap for COPD patients on Medicare will widen - not because of new drugs, but because of who can navigate the access system fastest.
Three signals are worth watching:
- Inhaler formulary churn will intensify as the primary access bottleneck. According to a March 2025 thread on r/FamilyMedicine, practicing physicians are already describing monthly scrambles to find covered COPD inhaler alternatives - and neither EPIC nor pharmacies can keep up. No digital tool currently solves this in real time. Advocates who develop live Part D formulary lookup capabilities will become the de facto routing layer for COPD maintenance prescriptions. The weak signal: prescribers are explicitly asking Reddit for a tool that does not yet exist. The implication: the advocate who builds the workflow first owns the highest-volume COPD intervention in Medicare Part D.
- CMS will face pressure to raise pulmonary rehab reimbursement toward cardiac rehab parity, but it will not arrive in this window. Clinical societies are documenting the gap publicly - pulmonary patients are sicker, more complex, and paid at less than half the rate of cardiac patients. Reimbursement parity would materially shift hospital investment in pulmonary programs. Until it does, advocates who secure post-discharge rehab slots are delivering the survival benefit that the payment system has not yet incentivized clinicians to pursue on their own. The signal to watch: ATS Pulmonary Rehabilitation Reimbursement Working Group activity.
- Family-driven ICU advocacy for COPD will grow, but slowly. Cases of ventilated COPD patients moved to hospice within days of intubation - despite 70-90% baseline ICU survival rates - are entering public view through YouTube and advocacy communities. The signal is early. Institutional response will lag. Independent ICU advocacy services will see demand growth before any health system formalizes a second-opinion standard.
What most families miss: they assume the bottleneck is drug access. It is not. The last new mechanism-of-action COPD therapeutic cleared FDA review in 2011. The drugs exist. The problem is that the advocate layer - real-time formulary management, post-discharge rehab coordination, and ICU second opinions - does not exist as a standard of care. That is the gap that will define COPD outcomes in 2026 and beyond.
Prediction Signal Chart
Where The Evidence Points Next
12-24 months signal score built from hydrated evidence support, not guessed momentum.
Over the next 12-24 months, Medicare COPD care will increasingly hinge on access friction (formulary churn, pulmonary rehab underutilization, ICU decision points) rather than drug innovation, making patient advocates the practical bridge between coverage rules and breathable out… These are the three signals with the strongest support in the current evidence library.
Support-weighted signal score
Sources: FamilyMedicine, ashp.org
Counter-signal: Medium
Counter-signal: Substack
Sources: YouTube
Counter-signal: thecurbsiders.com
Forward signal
Weak Signals Driving This Prediction
- Prescribers are already publicly admitting they 'rattle off inhaler names until one goes through' because EHRs and pharmacies cannot track…
- Pulmonary rehab pays less than half of cardiac rehab despite dose-dependent survival gains and depression benefits equivalent to medication…
- Public cases of ventilated COPD patients moved to hospice within 72 hours - despite 70-90% baseline ICU survival - are now circulating with…
The bottleneck for COPD patients is not new therapeutics or pulmonary rehab capacity - it is month-to-month inhaler formulary instability that no EHR or pharmacy can keep up with, which means advocates with live formula… Use the chart as a screening aid, not as a certainty machine.
What would change this forecast: A CMS rule freezing Part D mid-year inhaler formulary changes, a new mechanism-of-action COPD therapeutic clearing FDA review, or Medicare reimbursement parity between pulmonary and cardiac rehab would each materially s…
Methodology: authority-weighted support score from hydrated evidence
Key Takeaways
- Inhaler denials are systemic, not one-off errors. Medicare Part D formularies for COPD maintenance inhalers change month-to-month. Even EPIC EHR cannot track them in real time.
- Pulmonary rehab carries a 37% survival benefit when started within 90 days of a COPD hospitalization - but it is reimbursed at less than half the rate of cardiac rehab, limiting availability.
- 70-90% of ICU patients survive. A COPD patient on a ventilator is not necessarily at the end. Families have the right to medical records, weaning trial documentation, and a second opinion.
- No new mechanism-of-action COPD drug since 2011. The gap between good and poor outcomes is an access gap, not a treatment gap.
- Free advocacy starts at 1-877-839-2675 (SHIP). For COPD-specific navigation, condition-focused advocates with clinical teams are the strongest option.
What Is the Next Step for a COPD Patient on Medicare?
The next step is to identify which of the three access gaps is most urgent for you right now: an inhaler that was denied, a pulmonary rehab referral that was never made, or a care decision you were not ready to make.
According to GOLD 2025 guidelines, pulmonary rehab is not an optional add-on for high-risk COPD patients - it is an essential therapy, and the survival benefit is dose-dependent. National COPD treatment costs are projected to reach $49 billion as the population continues to age. The drug pipeline has not produced a new mechanism-of-action therapeutic since 2011. What this means is that the gap between excellent COPD outcomes and poor ones is increasingly an access gap, not a treatment gap. The patients with advocates get more of what works. The patients without advocates do not. That is the honest picture, and it is the reason this article exists.
If you or a family member is managing COPD on Medicare and you have run into a denied inhaler, a missed pulmonary rehab referral, or an ICU situation where you needed more answers - Understood Care's COPD advocacy team is available at 646-904-4027. The first conversation is no cost.
Is Your COPD Inhaler Covered? Is Pulmonary Rehab on Your Plan?
Understood Care's advocates help COPD patients on Medicare navigate inhaler denials, secure pulmonary rehab referrals, and push back when hospitals say there are no options. The initial assessment is no cost.
Call 646-904-4027 or visit understoodcare.com/uc-care-types/copd-support
Frequently Asked Questions
Does Medicare cover pulmonary rehab for COPD?
Medicare Part B covers pulmonary rehabilitation - a supervised program of exercise, education, and breathing techniques - for patients with moderate-to-severe COPD. Coverage is typically up to 36 sessions per benefit period, with up to 36 additional sessions approved with prior authorization. A patient advocate can help ensure the referral is made within the critical 90-day post-hospitalization window, where the survival benefit is 37%.
What should I do if Medicare denies my COPD inhaler?
Request a formulary exception or file a Medicare Part D appeal. The denial notice will include a specific reason code - that code tells your prescriber what documentation to provide. Most denials can be overturned with supporting clinical documentation. A patient advocate can check real-time formulary alternatives and file the appeal within CMS deadlines on your behalf.
Are patient advocate services free for Medicare patients?
Medicare does not pay for independent patient advocacy directly. Free counseling is available through SHIP (State Health Insurance Assistance Programs) at 1-877-839-2675. According to MSSP research, coordinated care organizations that managed chronic disease patients like those with COPD produced record savings while improving outcomes - proving the model works. For condition-specific advocacy including COPD, many organizations offer no-cost initial consultations.
Can a patient advocate help if the ICU recommends hospice for COPD?
Yes. Families have the right to the patient's full medical record, documentation of whether weaning trials were attempted, and an independent second opinion at any point during an ICU stay. An advocate can obtain and interpret that record, request specific clinical documentation, and arrange an independent pulmonology review before any end-of-life decision is made. The baseline ICU survival rate for critically ill patients is 70-90%.
What is the difference between a patient advocate and a hospital case manager for COPD?
A hospital case manager works for the health system and focuses on discharge planning and resource coordination within that system. An independent patient advocate works exclusively for the patient, has no institutional conflict of interest, and can challenge hospital or insurer decisions on the patient's behalf. For COPD patients navigating formulary disputes, pulmonary rehab appeals, or ICU second opinions, the distinction is significant.
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