Managing Diabetes (routine maintenance of existing condition) |
Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. Transfer this label to the Summary of Benefits and Coverage exactly as shown here. | |
Sample care costs: | ||
Pharmacy | $1,500 | |
Medical Equipment and Supplies | $1,300 | |
Office Visits & Procedures | $730 | |
Education | $290 | |
Laboratory Tests | $140 | |
Vaccines, Other Preventive | $140 | |
Total | $4,100 | |
Assumptions | ||
The following are assumptions that all group health plans and health insurance issuers must use for this scenario. | ||
Standard Assumptions | ||
These assumptions are standard across all scenarios. | ||
Costs do not include premiums. | ||
Condition was not excluded as a pre-existing condition. | ||
There are no other medical expenses for any member covered under the plan or policy. | ||
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.. No out-of-network charges or any other variation in Sample Care Costs. | ||
All services occur in same policy period. | ||
All prior authorizations were obtained. | ||
All services were deemed medically necessary. | ||
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth. | ||
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth. | ||
All medications are covered as generic equivalents if available. |
Medical Condition: | Type 2 Diabetes | |||||||
Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into that category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service under another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs" section. Examples of cost sharing and benefit features include, but are not limited to: • Payment of services based on the location such as inpatient, outpatient, or office; and • Payment of items as prescription drugs vs. medical equipment. Explanation of Scenario: Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded. Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered. ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service. ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service. CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC. Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider. Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab. Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code. Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing. Notes – includes any special notes for an item or service. CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. |
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Totals: | $4,094.99 | |||||||
Date of Service | Diagnosis Code (ICD-9) | Diagnosis Code (ICD-10) | CPT©, HCPCS, or Other Billing Code | Provider Type | Category | Descriptor | Allowed Amount | Notes |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885014201 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancing Device | $18.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885044801 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra 2 Blood Glucose Meter Kit | $66.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885041601 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Control Solution (2 vials/box) | $6.02 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Pharmacy | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $8.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00002803101 | Pharmacy Retail | Pharmacy | Glucagon Emergency Kit | $153.00 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 82947 | Primary | Laboratory tests | Assay Glucose Blood Quant | $6.43 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 82570 | Primary | Laboratory tests | Assay of Urine Creatinine | $7.17 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 80053 | Primary | Laboratory tests | Comprehen Metabolic Panel | $18.13 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 83036 | Primary | Laboratory tests | Glycosylated Hemoglobin Test | $14.07 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 80061 | Primary | Laboratory tests | Lipid panel | $19.23 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 82043 | Primary | Laboratory tests | Microalbumin Quantitative | $8.31 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 80069 | Primary | Laboratory tests | Renal Function Panel | $14.30 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 36415 | Primary | Laboratory tests | Routine Venipuncture | $4.13 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 81003 | Primary | Laboratory tests | Urinalysis Auto W/O Scope | $3.18 | |
3-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99214 | Primary | Office visits & procedures | Office/Outpatient Visit Est | $102.47 | |
4-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 98960 | Diabetes Educator | Education | Self-mgmt educ & train 1 pt | $80.53 | |
4-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 97803 | Dietician | Education | Med Nutrition Indiv Subseq | $63.13 | |
6-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99204 | Podiatry | Office visits & procedures | Office/Outpatient Visit New | $157.61 | Annual foot exam |
7-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99204 | Ophthalmology | Office visits & procedures | Office/Outpatient Visit New | $157.61 | Annual eye exam |
31-Jan | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
2-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
2-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
2-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
2-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
22-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
22-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
28-Feb | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
4-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
4-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
4-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
4-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
28-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Pharmacy | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $8.00 | |
28-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
28-Mar | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99214 | Primary | Office visits & procedures | Office/Outpatient Visit Est | $102.47 | |
3-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
3-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
3-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
3-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
13-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
13-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
25-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
3-May | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
3-May | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
3-May | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
3-May | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
23-Apr | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
23-May | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
2-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
20-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Pharmacy | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $8.00 | |
20-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 82947 | Primary | Laboratory tests | Assay Glucose Blood Quant | $6.43 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 83036 | Primary | Laboratory tests | Glycosylated Hemoglobin Test | $14.07 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 80069 | Primary | Laboratory tests | Renal Function Panel | $14.30 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 36415 | Primary | Laboratory tests | Routine Venipuncture | $4.13 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 81003 | Primary | Laboratory tests | Urinalysis Auto W/O Scope | $3.18 | |
27-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99214 | Primary | Office visits & procedures | Office/Outpatient Visit Est | $102.47 | |
28-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 98960 | Diabetes Educator | Education | Self-mgmt educ & train 1 pt | $80.53 | |
28-Jun | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 97803 | Dietician | Education | Med Nutrition Indiv Subseq | $63.13 | |
2-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
2-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
2-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885041601 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Control Solution (2 vials/box) | $6.02 | |
2-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
2-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
18-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
22-Jul | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
1-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
1-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
1-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
1-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
15-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
16-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
31-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
31-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
31-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
31-Aug | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
10-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
10-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
12-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Pharmacy | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $8.00 | |
12-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
26-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 99214 | Primary | Office visits & procedures | Office/Outpatient Visit Est | $102.47 | |
30-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
30-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
30-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
30-Sep | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
3-Oct | V03.82 | Z23 | 90472 | Primary | Vaccines, other preventive | Immunization admin each add | $13.44 | |
3-Oct | V03.82 | Z23 | 90471 | Primary | Vaccines, other preventive | Immunization Admin ADMIN | $13.44 | |
3-Oct | V03.82 | Z23 | 90669 | Primary | Vaccines, other preventive | Pneumococcal vacc 7 val im | $98.22 | |
3-Oct | V04.81 | Z23 | 90656 | Primary | Vaccines, other preventive | Flu Vaccine No Preserv 3 & > | $15.04 | |
10-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
30-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
30-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
30-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
30-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
30-Oct | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
7-Nov | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
29-Nov | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
29-Nov | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
29-Nov | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
29-Nov | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 | |
5-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Pharmacy | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $8.00 | |
5-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00088222033 | Pharmacy Retail | Pharmacy | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $11.92 | |
19-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885039310 | Pharmacy Retail | Medical equipment and supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $9.00 | |
19-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885024510 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $123.60 | |
29-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | OTC Medication | Pharmacy Retail | Medical equipment and supplies | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $3.00 | |
29-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 08290328279 | Pharmacy Retail | Medical equipment and supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $8.40 | |
29-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 53885041601 | Pharmacy Retail | Medical equipment and supplies | OneTouch Ultra Control Solution (2 vials/box) | $6.02 | |
29-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093104801 | Pharmacy Retail | Pharmacy | Metformin hydrochloride 500mg (Rx) [1 BID; #60 pills/month] | $34.37 | |
29-Dec | 250.00, V58.66, V58.67 | E11.9, Z79.82, Z79.4 | 00093743801 | Pharmacy Retail | Pharmacy | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $53.81 |
The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by provider type. This aids group health plans and health insurance issuers in applying benefits to each item and service. | |
Provider Type | What providers are covered under this Provider Type and other notes: |
Diabetes Educator | |
Dietitian | |
Emergency Room | |
Ophthalmology | |
Pharmacy Retail | |
Podiatry | |
Primary | Primary Care Physician or non-Specialist |
The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service so it rolls up to the same category in the Coverage Example label on the "Label and Assumptions" tab. This facilitates consistency between the "Scenario" tab and Coverage Example label. | |
Category | What services are covered under this Category and other notes: |
Office visits & procedures | Includes services by physicians and other providers. |
Education | |
Laboratory tests | Includes blood work |
Medical equipment & supplies | Includes durable medical equipment, orthotics, prosthetics |
Pharmacy | Includes all prescription drugs (generic, brand/preferred, non-preferred) which are not administered in a hospital, physician's office or other facility. The category also includes over-the-counter drugs. |
Vaccines, other preventive |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |