Managing-Type-2-Diabetes-Guide

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Label and Assumptions

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration d
(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)
Managing Type 2 Diabetes Instructions to Plans and Issuers:
Sample Care Cno data
Professional S
716
Professional Se
301
Diagnostic Ser
122
Prescription D
365
Prescription Dr
3125
Over-the-coun
22
Preventive Ser
159
Medical Suppli
790
Total (unroun
5601
No data
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 prod
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.
If applying the rounding rules causes the out-of-pocket amount displayed to exceed the actual out-of-pocket limit (for
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 ser
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a c
End of worksheet

Page 1

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.

Totals:
Date of
Service

$5,601.10
ICD-10
Diagnosis
Code

CPT©,
HCPCS, or
Other Billing
Code

This is a filter cell
This is a filter cell
This is a filter cell

Provider Type

Category

This is a filter cell

This is a filter cell

Description

Allowed Amount

This is a filter cell

This is a filter cell

BD Ultrafine Insulin Syringes / 30G/ 0.5cc
[usage = 30 syringes per month]
OneTouch Delica Lancets (100 per box)
[usage = 60 lancets per month]

3-Jan

No data

8290328279

Pharmacy Retail

Medical Supplies

3-Jan

No data

53885039310

Pharmacy Retail

Medical Supplies

3-Jan

No data

53885014201

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancing Device

$14.33

3-Jan

No data

53885044801

Pharmacy Retail

Medical Supplies

OneTouch Ultra 2 Blood Glucose Meter Kit

$14.70

3-Jan

No data

53885024510

Pharmacy Retail

Medical Supplies

OneTouch Ultra Blue Test Strips (Rx - box of
100) [usage = 2 strips/day; 60 per month]

$109.61

3-Jan

No data

53885041601

Pharmacy Retail

Medical Supplies

3-Jan

No data

OTC

Pharmacy Retail

Over-the-counter Drugs

3-Jan

No data

2803101

Pharmacy Retail

Prescription Drugs: Generic

OneTouch Ultra Control Solution (2
vials/box)
Aspirin 81mg (OTC - bottle 100) [usage = 1
QD; #30 pills per month]
Glucagon Emergency Kit

$20.62
$8.73

$6.63
$4.47
$241.05

Insulin glargine 100 unit/ml injectable
solution (Rx - 10ml vial) [20 units QD;
expires 28 days after first use]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[#60 pilles/month]

3-Jan

No data

88222033

Pharmacy Retail

3-Jan

No data

68382075810

Pharmacy Retail

3-Jan

No data

68180051503

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

3-Jan

No data

378395277

Pharmacy Retail

Prescription Drugs: Generic

82570

Primary

80053

Primary

83036

Primary

80061

Primary

82043

Primary

36415

Primary

99214

Primary

G0108

Diabetes Educator

97803

Dietician

99204

Podiatry

3-Jan
3-Jan
3-Jan
3-Jan
3-Jan
3-Jan
3-Jan
4-Jan
4-Jan
6-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
E119.00, Z7982,
Z794
E119.00, Z7982,
Z794
E119.00, Z7982,
Z794

Prescription Drugs: Insulin

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

$240.37
$3.21
$3.38

Atorvastatin 40 MG tablet 90 CT [ #30
pills/month]

$9.66

Assay of Urine Creatinine

$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

$77.82

Med Nutrition Indiv Subseq

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

7-Jan

E119.00, Z7982,
Z794

Professional Services:
Specialist

92014

Ophthalmology

31-Jan

No data

88222033

Pharmacy Retail

2-Feb

No data

8290328279

Pharmacy Retail

2-Feb

No data

68382075810

Pharmacy Retail

2-Feb

No data

68180051503

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

28-Feb

No data

88222033

Pharmacy Retail

Prescription Drugs: Insulin

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

$118.55

$240.37
$20.62
$3.21
$3.38
$240.37

BD Ultrafine Insulin Syringes / 30G/ 0.5cc
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]

4-Mar

No data

8290328279

Pharmacy Retail

Medical Supplies

4-Mar

No data

68382075810

Pharmacy Retail

4-Mar

No data

68180051503

Pharmacy Retail

28-Mar

No data

OTC

Pharmacy Retail

Over-the-counter Drugs

28-Mar

No data

88222033

Pharmacy Retail

Prescription Drugs: Insulin

28-Mar

E119.00, Z7982,
Z794

99214

Primary

Professional Services:
Primary Care

3-Apr

No data

8290328279

Pharmacy Retail

3-Apr

No data

68382075810

Pharmacy Retail

3-Apr

No data

68180051503

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

3-Apr

No data

378395277

Pharmacy Retail

Prescription Drugs: Generic

12-Apr

No data

53885039310

Pharmacy Retail

Medical Supplies

12-Apr

No data

53885024510

Pharmacy Retail

Medical Supplies

25-Apr

No data

88222033

Pharmacy Retail

3-May

No data

8290328279

Pharmacy Retail

3-May

No data

68382075810

Pharmacy Retail

3-May

No data

68180051503

Pharmacy Retail

23-May

No data

88222033

Pharmacy Retail

2-Jun

No data

8290328279

Pharmacy Retail

2-Jun

No data

68382075810

Pharmacy Retail

2-Jun

No data

68180051503

Pharmacy Retail

20-Jun

No data

603002632

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]
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

BD Ultrafine Insulin Syringes / 30G/ 0.5cc
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Medical Supplies

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
Medical Supplies
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Prescription Drugs: Insulin

Prescription Drugs: Generic 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
Medical Supplies
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Prescription Drugs: Insulin

$20.62
$3.21
$3.38
$4.47
$240.37
$121.70
$20.62
$3.21
$3.38
$9.66
$8.73
$109.61

$240.37
$20.62
$3.21
$3.38
$240.37
$20.62
$3.21

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$3.38

Aspirin 81mg (OTC - bottle 100) [usage = 1
QD; #30 pills per month]

$4.47

Over-the-counter Drugs

20-Jun
27-Jun
27-Jun
27-Jun

No data
E119.00, Z7982,
Z794
E119.00, Z7982,
Z794
E119.00, Z7982,
Z794

88222033

Pharmacy Retail

83036

Primary

36415

Primary

99214

Primary

Prescription Drugs: Insulin
Diagnostic Services:
Laboratory
Diagnostic Services:
Laboratory
Professional Services:
Primary Care

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

$240.37

Glycosylated Hemoglobin Test

$16.98

Routine Venipuncture

$6.43

Office/Outpatient Visit Est

$121.70

28-Jun

E119.00, Z7982,
Z794

G0108

Diabetes Educator

Professional Services:
Primary Care

Diabetes outpatient self-management
training services, individual, per 30 minutes

$77.82

28-Jun

E119.00, Z7982,
Z794

97803

Dietician

Professional Services:
Primary Care

Med Nutrition Indiv Subseq

$36.83

2-Jul

No data

8290328279

Pharmacy Retail

2-Jul

No data

53885041601

Pharmacy Retail

2-Jul

No data

68382075810

Pharmacy Retail

2-Jul

No data

68180051503

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

2-Jul

No data

378395277

Pharmacy Retail

Prescription Drugs: Generic

18-Jul

No data

88222033

Pharmacy Retail

Prescription Drugs: Insulin

21-Jul

No data

53885024510

Pharmacy Retail

Medical Supplies

21-Jul

No data

53885039310

Pharmacy Retail

1-Aug

No data

8290328279

Pharmacy Retail

1-Aug

No data

68382075810

Pharmacy Retail

1-Aug

No data

68180051503

Pharmacy Retail

15-Aug

No data

88222033

Pharmacy Retail

31-Aug

No data

8290328279

Pharmacy Retail

31-Aug

No data

68382075810

Pharmacy Retail

31-Aug

No data

68180051503

Pharmacy Retail

BD Ultrafine Insulin Syringes / 30G/ 0.5cc
[usage = 30 syringes per month]
OneTouch Ultra Control Solution (2
Medical Supplies
vials/box)
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Medical Supplies

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]

$20.62
$6.63
$3.21
$3.38
$9.66
$240.37

$109.61

OneTouch Delica Lancets (100 per box)
[usage = 60 lancets per month]
BD Ultrafine Insulin Syringes / 30G/ 0.5cc
Medical Supplies
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]

$20.62

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$3.38

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
Medical Supplies
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Prescription Drugs: Insulin

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$8.73

$3.21

$240.37
$20.62
$3.21
$3.38

12-Sep

No data

OTC

Pharmacy Retail

Over-the-counter Drugs

12-Sep

No data

88222033

Pharmacy Retail

Prescription Drugs: Insulin

26-Sep

E119.00, Z7982,
Z794

99214

Primary

Professional Services:
Primary Care

30-Sep

No data

8290328279

Pharmacy Retail

30-Sep

No data

68382075810

Pharmacy Retail

30-Sep

No data

68180051503

Pharmacy Retail

3-Oct

Z23

90472

Primary

3-Oct

Z23

90471

Primary

3-Oct

Z23

90732

Primary

3-Oct

Z23

90656

3-Oct

No data

10-Oct

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

BD Ultrafine Insulin Syringes / 30G/ 0.5cc
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Medical Supplies

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]
Preventive Services &
Vaccines
Preventive Services &
Vaccines

$4.47
$240.37
$121.70
$20.62
$3.21
$3.38

Immunization admin each add

$15.88

Immunization Admin

$28.31

Preventive Services &
Vaccines

Vaccine for pneumococcal polysaccharide
for injection beneath the skin or into
muscle, patient 2 years or older

$93.74

Primary

Preventive Services &
Vaccines

Flu Vaccine No Preserv 3 & >

$21.02

60505257909

Pharmacy Retail

Prescription Drugs: Generic

Atorvastatin 20 MG tablet 90 CT

$9.66

No data

88222033

Pharmacy Retail

Prescription Drugs: Insulin

30-Oct

No data

8290328279

Pharmacy Retail

Medical Supplies

29-Oct

No data

53885039310

Pharmacy Retail

Medical Supplies

29-Oct

No data

53885024510

Pharmacy Retail

Medical Supplies

OneTouch Ultra Blue Test Strips (Rx - box of
100) [usage = 2 strips/day; 60 per month]

$109.61

30-Oct

No data

68382075810

Pharmacy Retail

Prescription Drugs: Generic

Metformin Hydrochloride 500 MG TABLET
[ #60 pills/month]

$3.21

30-Oct

No data

68180051503

Pharmacy Retail

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$3.38

7-Nov

No data

88222033

Pharmacy Retail

29-Nov

No data

8290328279

Pharmacy Retail

29-Nov

No data

68382075810

Pharmacy Retail

29-Nov

No data

68180051503

Pharmacy Retail

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]

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
Medical Supplies
[usage = 30 syringes per month]
Metformin Hydrochloride 500 MG TABLET
Prescription Drugs: Generic
[ #60 pills/month]
Prescription Drugs: Insulin

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$240.37
$20.62
$8.73

$240.37
$20.62
$3.21
$3.38

5-Dec

No data

OTC

Pharmacy Retail

5-Dec

No data

88222033

Pharmacy Retail

29-Dec

No data

8290328279

Pharmacy Retail

29-Dec

No data

53885041601

Pharmacy Retail

29-Dec

No data

68382075810

Pharmacy Retail

29-Dec

No data

68180051503

Pharmacy Retail

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

Prescription Drugs: Generic Lisinopril 20mg (Rx) [1 QD; #30 pills/month]

$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.)
End of Worksheet

Provider Types

The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by pro
Provider Type What providers are covered under this Provider Type and other notes:
Pharmacy Retano data
Primary
Primary Care Physician or non-Specialist
Diabetes Educno data
Diatician
no data
Podiatry
no data
Ophthalmologno data
End of worksheet

Page 8

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
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
End of worksheet

What services are covered under this Category and other notes:
no data
no data
no data
no data
no data
no data
no data
no data