| Managing Type 2 Diabetes | Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab. | |
| Sample Care Costs | ||
| Professional Services: Primary Care | $791 | |
| Professional Services: Specialist | $273 | |
| Diagnostic Services: Laboratory | $134 | |
| Prescription Drugs: Generic | $676 | |
| Prescription Drugs: Branded | $3,582 | |
| Over-the-counter Drugs | $55 | |
| Preventive Services & Vaccines | $150 | |
| Medical Supplies | $1,728 | |
| Total (unrounded) | $7,389 | |
| 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. | ||
| If the plan has a wellness program that varies the deductibles, copayments, coinsurance, or coverage for any of the services listed in a treatment scenario, the plan or issuer must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program. | ||
| OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 | ||
| Medical Condition: | Managing 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. CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 |
|||||||
| Totals: | $7,389.29 | ||||||
| Date of Service | ICD-9 Diagnosis Code | ICD-10 Diagnosis Code | CPT©, HCPCS, or Other Billing Code | Provider Type | Category | Description | Allowed Amount |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885014201 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancing Device | $16.12 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885044801 | Pharmacy Retail | Medical Supplies | OneTouch Ultra 2 Blood Glucose Meter Kit | $56.90 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885041601 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Control Solution (2 vials/box) | $5.07 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $4.27 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 2803101 | Pharmacy Retail | Prescription Drugs: Generic | Glucagon Emergency Kit | $246.17 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 60505257909 | Pharmacy Retail | Prescription Drugs: Generic | Atorvastatin 20 MG tablet 90 CT | $25.88 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 82947 | Primary | Diagnostic Services: Laboratory | Assay Glucose Blood Quant | $5.73 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 82570 | Primary | Diagnostic Services: Laboratory | Assay of Urine Creatinine | $5.79 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 80053 | Primary | Diagnostic Services: Laboratory | Comprehen Metabolic Panel | $14.53 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 83036 | Primary | Diagnostic Services: Laboratory | Glycosylated Hemoglobin Test | $10.85 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 80061 | Primary | Diagnostic Services: Laboratory | Lipid panel | $14.42 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 82043 | Primary | Diagnostic Services: Laboratory | Microalbumin Quantitative | $6.32 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 80069 | Primary | Diagnostic Services: Laboratory | Renal Function Panel | $11.63 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 36415 | Primary | Diagnostic Services: Laboratory | Routine Venipuncture | $4.17 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 81003 | Primary | Diagnostic Services: Laboratory | Urinalysis Auto W/O Scope | $3.09 |
| 3-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 99214 | Primary | Professional Services: Primary Care | Office/Outpatient Visit Est | $107.87 |
| 4-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 98960 | Diabetes Educator | Professional Services: Primary Care | Self-mgmt educ & train 1 pt | $99.90 |
| 4-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 97803 | Dietician | Professional Services: Primary Care | Med Nutrition Indiv Subseq | $80.00 |
| 6-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 99204 | Podiatry | Professional Services: Specialist | Office/Outpatient Visit New | $165.00 |
| 7-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 92014 | Ophthalmology | Professional Services: Specialist | Ophthalmological services: medical examination & evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, 1 or more visits | $108.24 |
| 31-Jan | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 2-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 2-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 2-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 2-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 22-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 22-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 28-Feb | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 4-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 4-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 4-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 4-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 28-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $4.27 |
| 28-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 28-Mar | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 99214 | Primary | Professional Services: Primary Care | Office/Outpatient Visit Est | $107.87 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 60505257909 | Pharmacy Retail | Prescription Drugs: Generic | Atorvastatin 20 MG tablet 90 CT | $25.88 |
| 3-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 83036 | Primary | Diagnostic Services: Laboratory | Glycosylated Hemoglobin Test | $10.85 |
| 13-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 13-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 25-Apr | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 3-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 3-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 3-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 3-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 23-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 23-May | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 2-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 20-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $4.27 |
| 20-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 82947 | Primary | Diagnostic Services: Laboratory | Assay Glucose Blood Quant | $5.73 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 83036 | Primary | Diagnostic Services: Laboratory | Glycosylated Hemoglobin Test | $10.85 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 80069 | Primary | Diagnostic Services: Laboratory | Renal Function Panel | $11.63 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 36415 | Primary | Diagnostic Services: Laboratory | Routine Venipuncture | $4.17 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 81003 | Primary | Diagnostic Services: Laboratory | Urinalysis Auto W/O Scope | $3.09 |
| 27-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 99214 | Primary | Professional Services: Primary Care | Office/Outpatient Visit Est | $107.87 |
| 28-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 98960 | Diabetes Educator | Professional Services: Primary Care | Self-mgmt educ & train 1 pt | $99.90 |
| 28-Jun | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 97803 | Dietician | Professional Services: Primary Care | Med Nutrition Indiv Subseq | $80.00 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885041601 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Control Solution (2 vials/box) | $5.07 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 2-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 60505257909 | Pharmacy Retail | Prescription Drugs: Generic | Atorvastatin 20 MG tablet 90 CT | $25.88 |
| 18-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 22-Jul | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 1-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 1-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 1-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 1-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 15-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 16-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 31-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 31-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 31-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 31-Aug | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 10-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 10-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 12-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $4.27 |
| 12-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 26-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 99214 | Primary | Professional Services: Primary Care | Office/Outpatient Visit Est | $107.87 |
| 30-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 30-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 30-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 30-Sep | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 3-Oct | V03.82 | Z23 | 90472 | Primary | Preventive Services & Vaccines | Immunization admin each add | $14.98 |
| 3-Oct | V03.82 | Z23 | 90471 | Primary | Preventive Services & Vaccines | Immunization Admin | $23.00 |
| 3-Oct | V03.82 | Z23 | 90669 | Primary | Preventive Services & Vaccines | Pneumococcal vacc 7 val im | $97.86 |
| 3-Oct | V04.81 | Z23 | 90656 | Primary | Preventive Services & Vaccines | Flu Vaccine No Preserv 3 & > | $14.27 |
| 3-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 60505257909 | Pharmacy Retail | Prescription Drugs: Generic | Atorvastatin 20 MG tablet 90 CT | $25.88 |
| 3-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 83036 | Primary | Diagnostic Services: Laboratory | Glycosylated Hemoglobin Test | $10.85 |
| 10-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 30-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 30-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 30-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 30-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 30-Oct | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 7-Nov | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 29-Nov | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 29-Nov | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 29-Nov | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 29-Nov | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| 5-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] | $4.27 |
| 5-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 88222033 | Pharmacy Retail | Prescription Drugs: Branded | Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] | $275.51 |
| 19-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885039310 | Pharmacy Retail | Medical Supplies | OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] | $10.38 |
| 19-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885024510 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] | $125.26 |
| 29-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | OTC | Pharmacy Retail | Over-the-counter Drugs | Alcohol swabs (OTC - box of 100) [usage = 3 wipes/day; 90 wipes/month] | $2.61 |
| 29-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 8290328279 | Pharmacy Retail | Medical Supplies | BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] | $42.66 |
| 29-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 53885041601 | Pharmacy Retail | Medical Supplies | OneTouch Ultra Control Solution (2 vials/box) | $5.07 |
| 29-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93104901 | Pharmacy Retail | Prescription Drugs: Generic | METFORMIN HCL 850 MG TABLET | $9.19 |
| 29-Dec | 250.00, V58.66, V58.67 | E119.00, Z7982, Z794 | 93743801 | Pharmacy Retail | Prescription Drugs: Generic | Ramipril 10mg (Rx) [1 QD; #30 pills/month] | $15.92 |
| ** Inpatient costs were calculated based on national averages using the indicated DRG codes. Additional variances may occur based on how health plan hospital contracts are structured (e.g., case rate, per diems, percentage of billed charges, etc.) | |||||||
| 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: |
| Pharmacy Retail | |
| Primary | Primary Care Physician or non-Specialist |
| Diabetes Educator | |
| Diatician | |
| Podiatry | |
| Ophthalmology | |
| OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 | |
| 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: |
| Over-the-counter Drugs | |
| Medical Supplies | |
| Prescription Drugs: Generic | |
| Prescription Drugs: Branded | |
| Diagnostic Services: Laboratory | |
| Professional Services: Primary Care | |
| Professional Services: Specialist | |
| Preventive Services & Vaccines | |
| OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 | |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |