SBC Disclosure

OMB control number: 0938-1146
Expiration Date: XX/20XX

Managing Type 2 Diabetes Guide
Label and Assumptions
Instructions to Plans and Issuers: Do not modify this table. The numbers shown here come from the
Scenario table.
Table 1. Managing Type 2 Diabetes Sample Care Costs
Managing Type 2 Diabetes
Professional Services: Primary Care
Professional Services: Specialist
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Insulin
Over-the-counter Drugs
Preventative Services & Vaccines
Medical Supplies
Total

Sample Care Costs

$716
$301
$122
$365
$3,125
$22
$159
$790
$5,601

Assumptions
The following are assumptions that all group health plans and insurance issuers must use for this
scenario. 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 hundred.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the
nearest ten.
If applying the rounding rules causes the out-of-pocket amount displayed to exceed the actual
out-of-pocket limit (for self-only coverage), then the out-of-pocket limit amount must be shown
as the amount of the actual-out-of-pocket limit.
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 listed services 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

Scenario
Medical Condition: Managing Type 2 Diabetes
Note: Services 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.
• 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-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-thecounter 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.

Table 2. Managing Type 2 Diabetes Scenario Timeline
Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Category

Description

Totals:

Allowed
Amount

$5,601.10

3-Jan

8290328279

Pharmacy
Retail

Medical
Supplies

3-Jan

53885039310

Pharmacy
Retail

Medical
Supplies

3-Jan

53885014201

3-Jan

53885044801

Pharmacy
Retail
Pharmacy
Retail

Medical
Supplies
Medical
Supplies

3-Jan

53885024510

Pharmacy
Retail

Medical
Supplies

3-Jan

53885041601

3-Jan

OTC

Pharmacy
Retail
Pharmacy
Retail

Medical
Supplies
Over-thecounter
Drugs

3-Jan

2803101

Pharmacy
Retail

3-Jan

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

3-Jan

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

3-Jan

68180051503

Pharmacy
Retail

3-Jan

378395277

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Generic

BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
OneTouch Delica
Lancing Device
OneTouch Ultra 2
Blood Glucose Meter
Kit
OneTouch Ultra Blue
Test Strips (Rx - box of
100) [usage = 2
strips/day; 60 per
month]
OneTouch Ultra Control
Solution (2 vials/box)
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per
month]
Glucagon Emergency
Kit
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
Metformin
Hydrochloride 500 MG
TABLET [#60
pilles/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]
Atorvastatin 40 MG
tablet 90 CT [ #30
pills/month]

$20.62

$8.73

$14.33
$14.70
$109.61

$6.63
$4.47

$241.05
$240.37

$3.21

$3.38
$9.66

Date
ICD-10
of
Diagnosis
Service
Code
3-Jan
3-Jan
3-Jan
3-Jan
3-Jan
3-Jan
3-Jan

E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

82570

Primary

80053

Primary

83036

Primary

80061

Primary

82043

Primary

36415

Primary

99214

Primary

4-Jan

E119.00,
Z7982,
Z794

G0108

Diabetes
Educator

4-Jan

E119.00,
Z7982,
Z794

97803

Dietician

6-Jan

E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794

99204

Podiatry

92014

Ophthalmology

7-Jan

Category

Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Professional
Services:
Primary
Care
Professional
Services:
Primary
Care
Professional
Services:
Primary
Care
Professional
Services:
Specialist
Professional
Services:
Specialist

Description

Assay of Urine
Creatinine

Allowed
Amount

$9.53

Comprehen Metabolic
Panel

$29.63

Glycosylated
Hemoglobin Test

$16.98

Lipid panel

$23.40

Microalbumin
Quantitative

$13.10

Routine Venipuncture

$6.43

Office/Outpatient Visit
Est

$121.70

Diabetes outpatient
self-management
training services,
individual, per 30
minutes
Med Nutrition Indiv
Subseq

$77.82

$36.83

Office/Outpatient Visit
New

$182.19

Ophthalmological
services: medical
examination &
evaluation, with
initiation or
continuation of
diagnostic and
treatment program,
comprehensive,
established patient, 1
or more visits

$118.55

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Description

Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$240.37

Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$240.37

Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per
month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
Office/Outpatient Visit
Est

$4.47

31-Jan

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

2-Feb

8290328279

Pharmacy
Retail

Medical
Supplies

2-Feb

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

2-Feb

68180051503

Pharmacy
Retail

28-Feb

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

4-Mar

8290328279

Pharmacy
Retail

Medical
Supplies

4-Mar

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

4-Mar

68180051503

Pharmacy
Retail

28-Mar

OTC

Pharmacy
Retail

Prescription
Drugs:
Generic
Over-thecounter
Drugs

28-Mar

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

99214

Primary

Professional
Services:
Primary
Care

28-Mar

E119.00,
Z7982,
Z794

Allowed
Amount

Category

$20.62

$3.21

$3.38

$20.62

$3.21

$3.38

$240.37

$121.70

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Category

3-Apr

8290328279

Pharmacy
Retail

Medical
Supplies

3-Apr

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

3-Apr

68180051503

Pharmacy
Retail

3-Apr

378395277

Pharmacy
Retail

12-Apr

53885039310

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Generic
Medical
Supplies

12-Apr

53885024510

Pharmacy
Retail

Medical
Supplies

25-Apr

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

3-May

8290328279

Pharmacy
Retail

Medical
Supplies

3-May

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

3-May

68180051503

Pharmacy
Retail

23-May

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

Description

Allowed
Amount

BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$20.62

Atorvastatin 40 MG
tablet 90 CT [ #30
pills/month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
OneTouch Ultra Blue
Test Strips (Rx - box of
100) [usage = 2
strips/day; 60 per
month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$9.66

Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]

$3.21

$3.38

$8.73

$109.61

$240.37

$20.62

$3.21

$3.38
$240.37

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Category

2-Jun

8290328279

Pharmacy
Retail

Medical
Supplies

2-Jun

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

2-Jun

68180051503

Pharmacy
Retail

20-Jun

603002632

Pharmacy
Retail

Prescription
Drugs:
Generic
Over-thecounter
Drugs

20-Jun

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794
E119.00,
Z7982,
Z794

83036

Primary

36415

Primary

99214

Primary

28-Jun

E119.00,
Z7982,
Z794

G0108

Diabetes
Educator

Diagnostic
Services:
Laboratory
Diagnostic
Services:
Laboratory
Professional
Services:
Primary
Care
Professional
Services:
Primary
Care

28-Jun

E119.00,
Z7982,
Z794

97803

Dietician

2-Jul

8290328279

Pharmacy
Retail

Professional
Services:
Primary
Care
Medical
Supplies

2-Jul

53885041601

Pharmacy
Retail

Medical
Supplies

27-Jun
27-Jun
27-Jun

Description

Allowed
Amount

BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$20.62

Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per
month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
Glycosylated
Hemoglobin Test

$4.47

$3.21

$3.38

$240.37

$16.98

Routine Venipuncture

$6.43

Office/Outpatient Visit
Est

$121.70

Diabetes outpatient
self-management
training services,
individual, per 30
minutes
Med Nutrition Indiv
Subseq

$77.82

BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
OneTouch Ultra Control
Solution (2 vials/box)

$20.62

$36.83

$6.63

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Allowed
Amount

Category

Description

Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$3.21

Atorvastatin 40 MG
tablet 90 CT [ #30
pills/month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
OneTouch Ultra Blue
Test Strips (Rx - box of
100) [usage = 2
strips/day; 60 per
month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$9.66

2-Jul

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

2-Jul

68180051503

Pharmacy
Retail

2-Jul

378395277

Pharmacy
Retail

18-Jul

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

21-Jul

53885024510

Pharmacy
Retail

Medical
Supplies

21-Jul

53885039310

Pharmacy
Retail

Medical
Supplies

1-Aug

8290328279

Pharmacy
Retail

Medical
Supplies

1-Aug

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

1-Aug

68180051503

Pharmacy
Retail

15-Aug

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

31-Aug

8290328279

Pharmacy
Retail

Medical
Supplies

Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]

$3.38

$240.37

$109.61

$8.73

$20.62

$3.21

$3.38
$240.37

$20.62

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Description

Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$3.21

Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per
month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
Office/Outpatient Visit
Est

$4.47

31-Aug

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

31-Aug

68180051503

Pharmacy
Retail

12-Sep

OTC

Pharmacy
Retail

Prescription
Drugs:
Generic
Over-thecounter
Drugs

12-Sep

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

99214

Primary

30-Sep

8290328279

Pharmacy
Retail

Professional
Services:
Primary
Care
Medical
Supplies

30-Sep

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

30-Sep

68180051503

Pharmacy
Retail

Prescription
Drugs:
Generic
Preventive
Services &
Vaccines
Preventive
Services &
Vaccines
Preventive
Services &
Vaccines

26-Sep

E119.00,
Z7982,
Z794

3-Oct

Z23

90472

Primary

3-Oct

Z23

90471

Primary

3-Oct

Z23

90732

Primary

3-Oct

Z23

90656

Primary

Allowed
Amount

Category

Preventive
Services &
Vaccines

$3.38

$240.37

$121.70

BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

$20.62

Immunization admin
each add

$15.88

Immunization Admin

$28.31

Vaccine for
pneumococcal
polysaccharide for
injection beneath the
skin or into muscle,
patient 2 years or older
Flu Vaccine No Preserv
3&>

$93.74

$3.21

$3.38

$21.02

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Category

3-Oct

60505257909

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

10-Oct

88222033

Pharmacy
Retail

30-Oct

8290328279

Pharmacy
Retail

Medical
Supplies

29-Oct

53885039310

Pharmacy
Retail

Medical
Supplies

29-Oct

53885024510

Pharmacy
Retail

Medical
Supplies

30-Oct

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

30-Oct

68180051503

Pharmacy
Retail

7-Nov

88222033

Pharmacy
Retail

Prescription
Drugs:
Generic
Prescription
Drugs:
Insulin

29-Nov

8290328279

Pharmacy
Retail

Medical
Supplies

29-Nov

68382075810

Pharmacy
Retail

Prescription
Drugs:
Generic

29-Nov

68180051503

Pharmacy
Retail

Prescription
Drugs:
Generic

Description

Atorvastatin 20 MG
tablet 90 CT
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
OneTouch Ultra Blue
Test Strips (Rx - box of
100) [usage = 2
strips/day; 60 per
month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

Allowed
Amount

$9.66
$240.37

$20.62

$8.73

$109.61

$3.21

$3.38
$240.37

$20.62

$3.21

$3.38

Date
ICD-10
of
Diagnosis
Service
Code

CPT©,
HCPCS, or
Other Billing
Code

Provider Type

Category

5-Dec

OTC

Pharmacy
Retail

Over-thecounter
Drugs

5-Dec

88222033

Pharmacy
Retail

Prescription
Drugs:
Insulin

29-Dec

8290328279

Pharmacy
Retail

Medical
Supplies

29-Dec

53885041601

29-Dec

68382075810

Pharmacy
Retail
Pharmacy
Retail

Medical
Supplies
Prescription
Drugs:
Generic

29-Dec

68180051503

Pharmacy
Retail

Prescription
Drugs:
Generic

Description

Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per
month]
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires
28 days after first use]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes
per month]
OneTouch Ultra Control
Solution (2 vials/box)
Metformin
Hydrochloride 500 MG
TABLET [ #60
pills/month]
Lisinopril 20mg (Rx) [1
QD; #30 pills/month]

Allowed
Amount

$4.47

$240.37

$20.62

$6.63
$3.21

$3.38

** 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.)

Provider Types
The following are the provider types to use in the “Scenario table ~ "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.
Table 3. Managing Type 2 Diabetes Provider Types
Provider Type
Pharmacy Retail
Primary
Diabetes Educator
Dietician
Podiatry
Ophthalmology

What providers are covered under this Provider
Type and other notes:
Primary Care Physician or non-Specialist data

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 [Expiration date: XXXXX XX, 2022]

Categories
The following are the categories to use in the “Scenario” table ~ "Category" column to classify each item
and service so it rolls up to the same category in the Coverage Example label in the "Label and
Assumptions" table. This facilitates consistency between the "Scenario" table and Coverage Example
label.
Table 4. Managing Type 2 Diabetes Provider Types
Category
Over-the-counter Drugs
Medical Supplies
Prescription Drugs: Generic
Prescription Drugs: Insulin
Diagnostic Services: Laboratory
Professional Services: Primary Care
Professional Services: Specialist
Preventive Services & Vaccines

What providers are covered under this Category
and other notes:

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