SBC Disclosure

Summary of Benefits and Coverage and Uniform Glossary (CMS-10407)

CMS-10406 - Coverage Examples Calculator.xlsm

SBC Disclosure

OMB: 0938-1146

Document [xlsx]
Download: xlsx | pdf

Overview

WELCOME
BENEFIT_DESIGN
PLAN_INPUT_DATA
RESULTS_SUMMARY
DIABETES_TIMELINE
FRACTURE_TIMELINE

Sheet 1: WELCOME




Welcome to the Coverage Examples Cost Sharing Calculator




All insurer data entry fields are highlighted in orange.






The Cost Sharing Calculator operates in two modes.


Click the button that corresponds to the mode you want to use.







The user enters data for an individual plan and views the results.



The user loads data for multiple plans and runs the calculator.
The user can then browse the results for the individual plans, save


the results to an external file, or copy and paste the results for


the individual plans to a separate worksheet.




Sheet 2: BENEFIT_DESIGN







Single Plan Mode Plan Selection:

Enter or modify data for each plan.




Data entry fields are highlighted in orange.








Plan Name Plan 1















Benefit category Type of cost sharing that applies Cost sharing¹ Coverage Limits OOP
Benefit Deductible Co-payment Co-insurance per month per year limit applies?
Inpatient Hospital Care (Facility) Not Covered






Other Facility Services Not Covered






Emergency Department (Facility) Not Covered






Ambulance Not Covered






Professional Services: Primary Care Not Covered






Professional Services: Emergency Department Not Covered






Professional Services: Inpatient Not Covered






Professional Services: Specialist Not Covered






Professional Services: Obstetric Care (Bundled) Not Covered






Professional Services: Procedures & Other Not Covered






Professional Services: Physical Therapy Not Covered






Diagnostic Services: Radiology Not Covered






Diagnostic Services: Laboratory Not Covered






Prescription Drugs: Generic Not Covered






Prescription Drugs: Branded Not Covered






Prescription Drugs: Insulin Not Covered






Over-the-counter Drugs Not Covered






Preventive Services & Vaccines Not Covered






Durable Medical Equipment Not Covered






Medical Supplies Not Covered






Over-the-counter Medical Supplies Not Covered






Other Items & Services Not Covered






Plan Deductible







Rx Deductible







Deductible C







Deductible D







Individual Out-of-Pocket (OOP) Limit

$0













Additional Options Applies? # Visits





Begin Primary Care Cost-Sharing After A Set Number of Visits? No






Begin Primary Care Cost-Sharing Deductible or Coinsurance After a Set Number of Copays? No















¹ The benefit-specific deductible, copayment amount, or coinsurance rate that determines consumer liability.







² Outpatient services include non-professional Emergency Department services. Professional services fall under the Professional Services benefit categories.
















Sheet 3: PLAN_INPUT_DATA




































































































































































This worksheet contains the benefit parameters for multiple plans.


































































































































































You can copy and paste data for individual plans from an external source starting on row 8.














































































































































































































































































































































































































































































































Inpatient Hospital Care (Facility)





Other Facility Services





Emergency Department (Facility)





Ambulance





Professional Services: Primary Care





Professional Services: Emergency Department





Professional Services: Inpatient





Professional Services: Specialist





Professional Services: Obstetric Care (Bundled)





Professional Services: Procedures & Other





Professional Services: Physical Therapy





Diagnostic Services: Radiology





Diagnostic Services: Laboratory





Prescription Drugs: Generic





Prescription Drugs: Branded





Prescription Drugs: Insulin





Over-the-counter Drugs





Preventive Services & Vaccines





Durable Medical Equipment





Medical Supplies





Over-the-counter Medical Supplies





Other Items & Services





Begin Primary Care Cost-Sharing After A Set Number of Visits?
Begin Primary Care Cost-Sharing Deductible or Coinsurance After a Set Number of Copays?
PLAN_ID Plan deductible Rx deductible Deductible C Deductible D OOP Limit Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Cost sharing Type Benefit Deductible Co-payment Co-insurance Monthly Limits Annual Limits OOP Limit Applies Applies? # Visits Applies? # Visits
Plan 1




Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Not Covered





Applies? # Visits No
Plan 2


































































































































































Plan 3


































































































































































Plan 4


































































































































































Plan 5


































































































































































Plan 6


































































































































































Sheet 4: RESULTS_SUMMARY













Summary of Subscriber & Plan Payments





Select Plan:







Summary for Plan 2
















Maternity Example
Diabetes Type 2 Example













Plan Pays: $10,626


Plan Pays: $3,579

























Patient Pays*: $2,061


Patient Pays*: $2,022



Deductibles $1,000


Deductibles $1,950



Copayments $0


Copayments $50



Coinsurance $1,000


Coinsurance $0



Exclusions & Limits $61


Exclusions & Limits $22
































Foot Fracture Example


















Plan Pays: $1,167






























Patient Pays*: $1,633








Deductibles $1,005








Copayments $0








Coinsurance $628








Exclusions & Limits $0












































*Note: Patient Pays Amount is capped at the individual out of pocket limit. Total Amounts may not add up due to rounding.













Sheet 5: DIABETES_TIMELINE















































































1







Phase 1: Determine Covered Amount Phase 2: Apply OOP Limit Phase 3a: Apply Special cost sharing - Begin Primary Care cost-sharing after a set number of visits? Phase 3b: Apply special cost sharing: Begin primary care cost sharing deductible or coinsurance after a set number of copays? Phase 4: Apply monthly/annual limit Phase 5: Plan deductible Phase 5: Rx deductible Phase 5: Optional deductible C Phase 5: Optional deductible D Phase 5: Benefit deductible Phase 5 Summary Phase 6: Apply copay and coinsurance Phase 7: Calculate total subscriber pays Phase 8: Summarize payments by payer and phase category
Claim number Date Calendar Month Item or Service Code Description Benefit Category Cost-sharing type Allowed amount Service Not covered Remaining Covered Amount OPL Valid? OPL applies OPL Remaining OPL after previous subscriber payments Primary Care Visit? Begin Primary Care Cost-Sharing After A Set Number of Visits? # Visits Primary Care Prior Use Visit Covered at 100% by plan Remaining Covered Amount Primary Care Visit? Begin Primary Care Cost-Sharing Deductible or Coinsurance After a Set Number of Copays? # Visits Primary Care Prior Copay Paid Copay Value Subscriber-Paid Copay Plan Paid Remaining OPL Remaining Covered Amount Monthly Limit Valid? Monthly limit Prior use (month) Not Covered because monthly limit exceeded Annual Limit Valid? Annual limit Prior use (annual) Not Covered because use limit exceeded Total Not Covered because use limit exceeded Covered amount Uses Plan deductible? Plan Deductible Remaining plan deductible after previous subscriber payments subscriber pays toward plan deductible Uses rx deductible? Rx Deductible Remaining Rx deductible after previous subscriber payments subscriber pays toward Rx deductible Uses deductible C? Deductible C Remaining deductible C after previous subscriber payments subscriber pays toward deductible C Uses deductible D? Deductible D Remaining deductible D after previous subscriber payments subscriber pays toward deductible D Uses benefit deductible? Benefit deductible Remaining benefit deductible after previous subcriber payments subscriber pays toward benefit deductible subscriber pays toward any deductible Subscriber-paid deductible after applying OPL Remaining OPL Covered amount remaining after deductibles Uses Copay? Copay Value Copay Paid Uses Coinsurance? Coinsurance Value Coinsurance Paid Subscriber-paid costsharing after OPL Remaining OPL Allowed amount after copayment or coinsurance Total subscriber payment After OPL plan payment Service Not covered Exclusions Subscriber-paid deductible Subscriber-paid copayment Subscriber-paid coinsurance Allowable Charge ChkSum
1 01/03/2016 1 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - $0.00 - N/A N/A N/A N/A N/A - N/A $0.00 - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
2 01/03/2016 1 5 OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] Medical Supplies Not Covered $8.73 $8.73 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $8.73 - - - - 1
3 01/03/2016 1 3 OneTouch Delica Lancing Device Medical Supplies Not Covered $14.33 $14.33 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $14.33 - - - - 1
4 01/03/2016 1 7 OneTouch Ultra 2 Blood Glucose Meter Kit Medical Supplies Not Covered $14.70 $14.70 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $14.70 - - - - 1
5 01/03/2016 1 4 OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] Medical Supplies Not Covered $109.61 $109.61 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $109.61 - - - - 1
6 01/03/2016 1 6 OneTouch Ultra Control Solution (2 vials/box) Medical Supplies Not Covered $6.63 $6.63 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $6.63 - - - - 1
7 01/03/2016 1 26 Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] Over-the-counter Drugs Not Covered $4.47 $4.47 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $4.47 - - - - 1
8 01/03/2016 1 1 Glucagon Emergency Kit Prescription Drugs: Generic Not Covered $241.05 $241.05 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $241.05 - - - - 1
9 01/03/2016 1 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
10 01/03/2016 1 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
11 01/03/2016 1 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
12 01/03/2016 1 33 Atorvastatin 40 MG tablet 90 CT [ #30 pills/month] Prescription Drugs: Generic Not Covered $9.66 $9.66 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $9.66 - - - - 1
13 01/03/2016 1 13 Assay of Urine Creatinine Diagnostic Services: Laboratory Not Covered $9.53 $9.53 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $9.53 - - - - 1
14 01/03/2016 1 8 Comprehen Metabolic Panel Diagnostic Services: Laboratory Not Covered $29.63 $29.63 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $29.63 - - - - 1
15 01/03/2016 1 16 Glycosylated Hemoglobin Test Diagnostic Services: Laboratory Not Covered $16.98 $16.98 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $16.98 - - - - 1
16 01/03/2016 1 9 Lipid panel Diagnostic Services: Laboratory Not Covered $23.40 $23.40 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $23.40 - - - - 1
17 01/03/2016 1 12 Microalbumin Quantitative Diagnostic Services: Laboratory Not Covered $13.10 $13.10 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $13.10 - - - - 1
18 01/03/2016 1 2 Routine Venipuncture Diagnostic Services: Laboratory Not Covered $6.43 $6.43 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $6.43 - - - - 1
19 01/03/2016 1 24 Office/Outpatient Visit Est Professional Services: Primary Care Not Covered $121.70 $121.70 - - No . N/A $1.00 . N/A 0 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $121.70 - - - - 1
20 01/04/2016 1 21 Diabetes outpatient self-management training services, individual, per 30 minutes Professional Services: Primary Care Not Covered $77.82 $77.82 - - No . N/A $1.00 . N/A 1 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $77.82 - - - - 1
21 01/04/2016 1 20 Med Nutrition Indiv Subseq Professional Services: Primary Care Not Covered $36.83 $36.83 - - No . N/A $1.00 . N/A 2 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $36.83 - - - - 1
22 01/06/2016 1 23 Office/Outpatient Visit New Professional Services: Specialist Not Covered $182.19 $182.19 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $182.19 - - - - 1
23 01/07/2016 1 22 Ophthalmological services: medical examination & evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, 1 or more visits Professional Services: Specialist Not Covered $118.55 $118.55 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $118.55 - - - - 1
24 01/31/2016 1 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 1 N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
25 02/02/2016 2 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
26 02/02/2016 2 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
27 02/02/2016 2 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
28 02/28/2016 2 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
29 03/04/2016 3 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
30 03/04/2016 3 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
31 03/04/2016 3 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
32 03/28/2016 3 26 Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] Over-the-counter Drugs Not Covered $4.47 $4.47 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $4.47 - - - - 1
33 03/28/2016 3 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
34 03/28/2016 3 24 Office/Outpatient Visit Est Professional Services: Primary Care Not Covered $121.70 $121.70 - - No . N/A $1.00 . N/A 3 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $121.70 - - - - 1
35 04/03/2016 4 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
36 04/03/2016 4 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
37 04/03/2016 4 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
38 04/03/2016 4 33 Atorvastatin 40 MG tablet 90 CT [ #30 pills/month] Prescription Drugs: Generic Not Covered $9.66 $9.66 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $9.66 - - - - 1
39 04/12/2016 4 5 OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] Medical Supplies Not Covered $8.73 $8.73 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $8.73 - - - - 1
40 04/12/2016 4 4 OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] Medical Supplies Not Covered $109.61 $109.61 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $109.61 - - - - 1
41 04/25/2016 4 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 4 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
42 05/03/2016 5 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 4 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
43 05/03/2016 5 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 4 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
44 05/03/2016 5 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 4 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
45 05/23/2016 5 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 5 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
46 06/02/2016 6 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 5 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
47 06/02/2016 6 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 5 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
48 06/02/2016 6 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 5 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
49 06/20/2016 6 26 Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] Over-the-counter Drugs Not Covered $4.47 $4.47 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $4.47 - - - - 1
50 06/20/2016 6 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 6 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
51 06/27/2016 6 16 Glycosylated Hemoglobin Test Diagnostic Services: Laboratory Not Covered $16.98 $16.98 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $16.98 - - - - 1
52 06/27/2016 6 2 Routine Venipuncture Diagnostic Services: Laboratory Not Covered $6.43 $6.43 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $6.43 - - - - 1
53 06/27/2016 6 24 Office/Outpatient Visit Est Professional Services: Primary Care Not Covered $121.70 $121.70 - - No . N/A $1.00 . N/A 4 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $121.70 - - - - 1
54 06/28/2016 6 21 Diabetes outpatient self-management training services, individual, per 30 minutes Professional Services: Primary Care Not Covered $77.82 $77.82 - - No . N/A $1.00 . N/A 5 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $77.82 - - - - 1
55 06/28/2016 6 20 Med Nutrition Indiv Subseq Professional Services: Primary Care Not Covered $36.83 $36.83 - - No . N/A $1.00 . N/A 6 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $36.83 - - - - 1
56 07/02/2016 7 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 6 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
57 07/02/2016 7 6 OneTouch Ultra Control Solution (2 vials/box) Medical Supplies Not Covered $6.63 $6.63 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $6.63 - - - - 1
58 07/02/2016 7 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 6 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
59 07/02/2016 7 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 6 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
60 07/02/2016 7 33 Atorvastatin 40 MG tablet 90 CT [ #30 pills/month] Prescription Drugs: Generic Not Covered $9.66 $9.66 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $9.66 - - - - 1
61 07/18/2016 7 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 7 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
62 07/21/2016 7 5 OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] Medical Supplies Not Covered $8.73 $8.73 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $8.73 - - - - 1
63 07/21/2016 7 4 OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] Medical Supplies Not Covered $109.61 $109.61 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $109.61 - - - - 1
64 08/01/2016 8 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 7 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
65 08/01/2016 8 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 7 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
66 08/01/2016 8 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 7 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
67 08/15/2016 8 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 8 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
68 08/31/2016 8 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 1 N/A - . 8 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
69 08/31/2016 8 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 1 N/A - . 8 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
70 08/31/2016 8 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 1 N/A - . 8 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
71 09/12/2016 9 26 Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] Over-the-counter Drugs Not Covered $4.47 $4.47 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $4.47 - - - - 1
72 09/12/2016 9 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 9 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
73 09/26/2016 9 24 Office/Outpatient Visit Est Professional Services: Primary Care Not Covered $121.70 $121.70 - - No . N/A $1.00 . N/A 7 - - $1.00 . N/A 0 N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $121.70 - - - - 1
74 09/30/2016 9 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 9 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
75 09/30/2016 9 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 9 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
76 09/30/2016 9 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 9 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
77 10/03/2016 10 28 Immunization admin each add Preventive Services & Vaccines Not Covered $15.88 $15.88 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $15.88 - - - - 1
78 10/03/2016 10 27 Immunization Admin ADMIN Preventive Services & Vaccines Not Covered $28.31 $28.31 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $28.31 - - - - 1
79 10/03/2016 10 29 Vaccine for pneumococcal polysaccharide for injection beneath the skin or into muscle, patient 2 years or older Preventive Services & Vaccines Not Covered $93.74 $93.74 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $93.74 - - - - 1
80 10/03/2016 10 30 Flu Vaccine No Preserv 3 & > Preventive Services & Vaccines Not Covered $21.02 $21.02 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $21.02 - - - - 1
81 10/03/2016 10 33 Atorvastatin 40 MG tablet 90 CT [ #30 pills/month] Prescription Drugs: Generic Not Covered $9.66 $9.66 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $9.66 - - - - 1
82 10/10/2016 10 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 10 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
83 10/29/2016 10 5 OneTouch Delica Lancets (100 per box) [usage = 60 lancets per month] Medical Supplies Not Covered $8.73 $8.73 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $8.73 - - - - 1
84 10/29/2016 10 4 OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month] Medical Supplies Not Covered $109.61 $109.61 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 3 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $109.61 - - - - 1
85 10/30/2016 10 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 10 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
86 10/30/2016 10 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 10 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
87 10/30/2016 10 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 10 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
88 11/07/2016 11 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 11 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
89 11/29/2016 11 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 11 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
90 11/29/2016 11 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 11 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
91 11/29/2016 11 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 11 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1
92 12/05/2016 12 26 Aspirin 81mg (OTC - bottle 100) [usage = 1 QD; #30 pills per month] Over-the-counter Drugs Not Covered $4.47 $4.47 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 4 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $4.47 - - - - 1
93 12/05/2016 12 17 Insulin glargine 100 unit/ml injectable solution (Rx - 10ml vial) [20 units QD; expires 28 days after first use] Prescription Drugs: Insulin Not Covered $240.37 $240.37 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 12 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $240.37 - - - - 1
94 12/29/2016 12 14 BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month] Medical Supplies Not Covered $20.62 $20.62 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 12 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $20.62 - - - - 1
95 12/29/2016 12 6 OneTouch Ultra Control Solution (2 vials/box) Medical Supplies Not Covered $6.63 $6.63 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $6.63 - - - - 1
96 12/29/2016 12 32 Metformin Hydrochloride 500 MG TABLET [ #60 pills/month] Prescription Drugs: Generic Not Covered $3.21 $3.21 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 12 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.21 - - - - 1
97 12/29/2016 12 19 Lisinopril 20mg (Rx) [1 QD; #30 pills/month] Prescription Drugs: Generic Not Covered $3.38 $3.38 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . 12 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $3.38 - - - - 1

Sheet 6: FRACTURE_TIMELINE















































































1







Phase 1: Determine Covered Amount Phase 2: Apply OOP Limit Phase 3a: Apply Special cost sharing - Begin Primary Care cost-sharing after a set number of visits? Phase 3b: Apply special cost sharing: Begin primary care cost sharing deductible or coinsurance after a set number of copays? Phase 4: Apply monthly/annual limit Phase 5: Plan deductible Phase 5: Rx deductible Phase 5: Optional deductible C Phase 5: Optional deductible D Phase 5: Benefit deductible Phase 5 Summary Phase 6: Apply copay and coinsurance Phase 7: Calculate total subscriber pays Phase 8: Summarize payments by payer and phase category
Claim number Date Calendar Month Item or Service Code Description Benefit Category Cost-sharing type Allowed amount Service Not covered Remaining Covered Amount OPL Valid? OPL applies OPL Remaining OPL after previous subscriber payments Primary Care Visit? Begin Primary Care Cost-Sharing After A Set Number of Visits? # Visits Primary Care Prior Use Visit Covered at 100% by plan Remaining Covered Amount Primary Care Visit? Begin Primary Care Cost-Sharing Deductible or Coinsurance After a Set Number of Copays? # Visits Primary Care Prior Copay Paid Copay Value Subscriber-Paid Copay Plan Paid Remaining OPL Remaining Covered Amount Monthly Limit Valid? Monthly limit Prior use (month) Not Covered because monthly limit exceeded Annual Limit Valid? Annual limit Prior use (annual) Not Covered because use limit exceeded Total Not Covered because use limit exceeded Covered amount Uses Plan deductible? Plan Deductible Remaining plan deductible after previous subscriber payments subscriber pays toward plan deductible Uses rx deductible? Rx Deductible Remaining Rx deductible after previous subscriber payments subscriber pays toward Rx deductible Uses deductible C? Deductible C Remaining deductible C after previous subscriber payments subscriber pays toward deductible C Uses deductible D? Deductible D Remaining deductible D after previous subscriber payments subscriber pays toward deductible D Uses benefit deductible? Benefit deductible Remaining benefit deductible after previous subcriber payments subscriber pays toward benefit deductible subscriber pays toward any deductible Subscriber-paid deductible after applying OPL Remaining OPL Covered amount remaining after deductibles Uses Copay? Copay Value Copay Paid Uses Coinsurance? Coinsurance Value Coinsurance Paid Subscriber-paid costsharing after OPL Remaining OPL Allowed amount after copayment or coinsurance Total subscriber payment After OPL plan payment Service Not covered Exclusions Subscriber-paid deductible Subscriber-paid copayment Subscriber-paid coinsurance Allowable Charge ChkSum
1 06/02/2016 6 2 Ground mileage, per statute mile Ambulance Not Covered $161.71 $161.71 - - No . N/A - N/A N/A N/A - $0.00 - N/A N/A N/A N/A N/A - N/A $0.00 - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $161.71 - - - - 1
2 06/02/2016 6 18 Ambulance service, basic life support, emergency transport (bls-emergency) Ambulance Not Covered $782.16 $782.16 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $782.16 - - - - 1
3 06/02/2016 6 4 Emergency department visit for evaluation and management of patient, which req 3 key components. Usually, presenting problem(s) are high severity, & require urgent physician evaluation but do not pose Emergency Department (Facility) Not Covered $357.31 $357.31 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $357.31 - - - - 1
4 06/02/2016 6 5 Radiologic examination, foot; complete, minimum of 3 views Professional Services: Emergency Department Not Covered $49.72 $49.72 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $49.72 - - - - 1
5 06/02/2016 6 6 Closed treatment of metatarsal fracture; without manipulation, each Professional Services: Emergency Department Not Covered $335.16 $335.16 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $335.16 - - - - 1
6 06/02/2016 6 19 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf Durable Medical Equipment Not Covered $211.56 $211.56 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $211.56 - - - - 1
7 06/02/2016 6 9 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips, and handgrips Durable Medical Equipment Not Covered $35.97 $35.97 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $35.97 - - - - 1
8 06/02/2016 6 8 Week supply of Acetaminophen 300 MG / Codeine Phosphate 30 MG Oral Tablet Prescription Drugs: Generic Not Covered $5.24 $5.24 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $5.24 - - - - 1
9 06/09/2016 6 11 Office or other outpatient visit for the evaluation and management of a new patient, which requires at least 3 key components. Physicians typically spend 30 minutes face-to-face with the patient. Professional Services: Specialist Not Covered $127.51 $127.51 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $127.51 - - - - 1
10 06/09/2016 6 7 Radiologic examination, foot; complete, minimum of 3 views Diagnostic Services: Radiology Not Covered $49.72 $49.72 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $49.72 - - - - 1
11 06/09/2016 6 12 Application of short leg cast (below knee to toes); Professional Services: Specialist Not Covered $132.03 $132.03 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $132.03 - - - - 1
12 06/09/2016 6 13 Cast supplies, short leg cast, adult (11 years +), fiberglass Other Facility Services Not Covered $43.22 $43.22 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $43.22 - - - - 1
13 07/14/2016 7 14 X-ray of ankle, minimum of 3 views Diagnostic Services: Radiology Not Covered $63.18 $63.18 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $63.18 - - - - 1
14 07/14/2016 7 15 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of 3 key components. Physicians typically spend 15 minutes face-to-face with the Professional Services: Specialist Not Covered $81.66 $81.66 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $81.66 - - - - 1
15 08/04/2016 8 16 Physical therapy evaluation Professional Services: Physical Therapy Not Covered $116.43 $116.43 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $116.43 - - - - 1
16 08/11/2016 8 17 Therapeutic procedure, 1 or more areas, 2 sessions (15 minutes/session); therapeutic exercises to develop strength and endurance, range of motion and flexibility. Professional Services: Physical Therapy Not Covered $82.53 $82.53 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . - N/A - . - N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $82.53 - - - - 1
17 08/11/2016 8 17 Therapeutic procedure, 1 or more areas, 2 sessions (15 minutes/session); therapeutic exercises to develop strength and endurance, range of motion and flexibility. Professional Services: Physical Therapy Not Covered $82.53 $82.53 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 1 N/A - . 1 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $82.53 - - - - 1
18 08/18/2016 8 17 Therapeutic procedure, 1 or more areas, 2 sessions (15 minutes/session); therapeutic exercises to develop strength and endurance, range of motion and flexibility. Professional Services: Physical Therapy Not Covered $82.53 $82.53 - - No . N/A - N/A N/A N/A - - - N/A N/A N/A N/A N/A - N/A - - . 2 N/A - . 2 N/A - - 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A 0 N/A N/A N/A - - N/A - $0.00 N/A N/A $0.00 N/A N/A - N/A - - - $82.53 - - - - 1
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