Summary of Benefits and Coverage

Summary of Benefits and Coverage and Uniform Glossary Required Under the Affordable Care Act

Managing Type 2 Diabetes April 2017.xlsx

Summary of Benefits and Coverage

OMB: 1210-0147

Document [xlsx]
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Overview

Label and Assumptions
Scenario
Provider Types
Categories


Sheet 1: Label and Assumptions

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


Sheet 2: Scenario

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.)







Sheet 3: Provider Types

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

Sheet 4: Categories

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 Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

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