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pdfManaging type 2 diabetes
Instructions to Plans and Issuers:
(routine maintenance of a well-controlled condition)
Do not modify this tab. The numbers shown
here roll up from the Scenario tab.
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those
products that incorporate tiered provider networks.. No out-of-network charges or any other variation in Sample Care
Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
All medications are covered as generic equivalents if available.
If the plan has a wellness program that varies the deductibles, co-payments, co-insurance, or coverage for any of the
services listed in a treatment scenario, the plan must complete the calculations for that treatment scenario assuming that
the patient is participating in the wellness program. networks.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
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.
Notes – includes any special notes for an item or service.
CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Medical Condition:
Type 2 Diabetes
Totals:
Date of
Service
$
Diagnosis Code (ICD9)
Diagnosis Code
(ICD-10)
CPT©, HCPCS, or Other
Billing Code
Provider Type
Category
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885014201
Pharmacy Retail
Medical equipment
and supplies
Alcohol swabs (OTC box of 100) [usage = 3
wipes/day; 90
wipes/month]
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
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885044801
Pharmacy Retail
Medical equipment
and supplies
OneTouch Ultra 2 Blood
Glucose Meter Kit
5,126.92
Allowed
Amount
Descriptor
$
3.00
$
8.40
$
9.00
$
18.00
$
66.00
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885041601
Pharmacy Retail
Medical equipment
and supplies
OneTouch Ultra Control
Solution (2 vials/box)
$
6.02
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Pharmacy
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per month]
$
8.00
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00002803101
Pharmacy Retail
Pharmacy
Glucagon Emergency
Kit
$
153.00
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
$
34.37
$
53.81
$
6.43
$
7.17
$
18.13
$
14.07
$
19.23
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
82947
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
82570
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
80053
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
83036
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
80061
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
82043
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
80069
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
36415
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
81003
Primary
Laboratory tests
03-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99214
Primary
Office visits &
procedures
04-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
98960
Diabetes Educator
Education
04-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
97803
Dietician
Education
06-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99204
Podiatry
07-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99204
Ophthalmology
Office visits &
procedures
Office visits &
procedures
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
Assay Glucose Blood
Quant
Assay of Urine
Creatinine
Comprehen Metabolic
Panel
Glycosylated
Hemoglobin Test
Lipid panel
Microalbumin
Quantitative
Renal Function Panel
Routine Venipuncture
Urinalysis Auto W/O
Scope
Office/Outpatient Visit
Est
Self-mgmt educ & train
1 pt
Med Nutrition Indiv
Subseq
Office/Outpatient Visit
New
Office/Outpatient Visit
New
31-Jan
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
02-Feb
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
Alcohol swabs (OTC box of 100) [usage = 3
wipes/day; 90
wipes/month]
$
8.31
$
14.30
$
4.13
$
3.18
$
102.47
$
80.53
$
63.13
$
157.61
$
157.61
$
119.20
$
3.00
Notes
Annual foot
exam
Annual eye
exam
Date of
Service
Diagnosis Code (ICD9)
02-Feb
Diagnosis Code
(ICD-10)
CPT©, HCPCS, or Other
Billing Code
Provider Type
Category
Descriptor
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
02-Feb
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
22-Feb
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
22-Feb
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
Allowed
Amount
$
34.37
$
53.81
$
9.00
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
119.20
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
28-Feb
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
04-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
04-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
04-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
04-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
28-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Pharmacy
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per month]
$
8.00
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
28-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
28-Mar
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99214
Primary
Office visits &
procedures
03-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
03-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
03-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
03-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
13-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
13-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
25-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
03-May
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
03-May
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
$
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
Office/Outpatient Visit
$
Est
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
3.00
8.40
102.47
3.00
8.40
$
34.37
$
53.81
$
9.00
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
119.20
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
$
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
3.00
8.40
Notes
Date of
Service
Diagnosis Code (ICD9)
Diagnosis Code
(ICD-10)
CPT©, HCPCS, or Other
Billing Code
Provider Type
Category
03-May
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
23-Apr
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
23-May
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
Allowed
Amount
Descriptor
Ramipril 10mg (Rx) [1
QD; #30 pills/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]
$
53.81
$
9.00
$
119.20
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
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]
3.00
8.40
9.00
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
02-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
20-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Pharmacy
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per month]
$
8.00
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
$
6.43
$
14.07
$
14.30
$
4.13
$
3.18
$
102.47
$
80.53
$
63.13
$
3.00
$
8.40
123.60
20-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
82947
Primary
Laboratory tests
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
83036
Primary
Laboratory tests
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
80069
Primary
Laboratory tests
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
36415
Primary
Laboratory tests
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
81003
Primary
Laboratory tests
27-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99214
Primary
Office visits &
procedures
28-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
98960
Diabetes Educator
Education
28-Jun
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
97803
Dietician
Education
02-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
02-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
02-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885041601
Pharmacy Retail
Medical equipment
and supplies
OneTouch Ultra Control
Solution (2 vials/box)
$
6.02
02-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
02-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
Pharmacy
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
18-Jul
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Assay Glucose Blood
Quant
Glycosylated
Hemoglobin Test
Renal Function Panel
Routine Venipuncture
Urinalysis Auto W/O
Scope
Office/Outpatient Visit
Est
Self-mgmt educ & train
1 pt
Med Nutrition Indiv
Subseq
Alcohol swabs (OTC box of 100) [usage = 3
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes per
month]
Notes
Date of
Service
Diagnosis Code (ICD9)
Diagnosis Code
(ICD-10)
CPT©, HCPCS, or Other
Billing Code
Provider Type
Category
Allowed
Amount
Descriptor
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
01-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
01-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
01-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
01-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
3.00
8.40
15-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
16-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
31-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
31-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
31-Aug
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
10-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
10-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
12-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Pharmacy
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per month]
$
8.00
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
12-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
26-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
99214
Primary
Office visits &
procedures
30-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
30-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
30-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
30-Sep
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
03-Oct
V03.82
Z23
90472
Primary
03-Oct
V03.82
Z23
90471
Primary
03-Oct
V03.82
Z23
90669
Primary
03-Oct
V04.81
Z23
90656
Primary
OTC Medication
Pharmacy Retail
30-Oct
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
Vaccines, other
preventive
Vaccines, other
preventive
Vaccines, other
preventive
Vaccines, other
preventive
Medical equipment
and supplies
Alcohol swabs (OTC box of 100) [usage = 3
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
[usage = 30 syringes per
month]
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
$
3.00
$
8.40
$
53.81
$
9.00
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
Office/Outpatient Visit
$
Est
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
Immunization admin
each add
Immunization Admin
ADMIN
Pneumococcal vacc 7
val im
Flu Vaccine No Preserv
3&>
Alcohol swabs (OTC box of 100) [usage = 3
wipes/day; 90
wipes/month]
102.47
3.00
8.40
$
34.37
$
53.81
$
13.44
$
13.44
$
98.22
$
15.04
$
3.00
Notes
Date of
Service
Diagnosis Code (ICD9)
Diagnosis Code
(ICD-10)
CPT©, HCPCS, or Other
Billing Code
Provider Type
Category
Allowed
Amount
Descriptor
30-Oct
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
30-Oct
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
30-Oct
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
$
119.20
$
9.00
07-Nov
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
29-Nov
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
29-Nov
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
29-Nov
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
05-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Pharmacy
Aspirin 81mg (OTC bottle 100) [usage = 1
QD; #30 pills per month]
$
8.00
$
119.20
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
Ramipril 10mg (Rx) [1
$
QD; #30 pills/month]
3.00
8.40
53.81
05-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00088222033
Pharmacy Retail
Pharmacy
Insulin glargine 100
unit/ml injectable
solution (Rx - 10ml vial)
[20 units QD; expires 28
days after first use]
19-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885039310
Pharmacy Retail
Medical equipment
and supplies
OneTouch Delica
Lancets (100 per box)
[usage = 60 lancets per
month]
$
9.00
OneTouch Ultra Blue
Test Strips (Rx - box of
$
100) [usage = 2
strips/day; 60 per month]
123.60
19-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885024510
Pharmacy Retail
Medical equipment
and supplies
29-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
OTC Medication
Pharmacy Retail
Medical equipment
and supplies
29-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
08290328279
Pharmacy Retail
Medical equipment
and supplies
29-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
53885041601
Pharmacy Retail
Medical equipment
and supplies
OneTouch Ultra Control
Solution (2 vials/box)
$
6.02
29-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093104801
Pharmacy Retail
Pharmacy
Metformin hydrochloride
500mg (Rx) [1 BID; #60
pills/month]
$
34.37
29-Dec
250.00, V58.66, V58.67 E11.9, Z79.82, Z79.4
00093743801
Pharmacy Retail
Pharmacy
Ramipril 10mg (Rx) [1
QD; #30 pills/month]
$
53.81
Alcohol swabs (OTC box of 100) [usage = 3
$
wipes/day; 90
wipes/month]
BD Ultrafine Insulin
Syringes / 30G/ 0.5cc
$
[usage = 30 syringes per
month]
3.00
8.40
Notes
The following are the provider types to use on the "Scenario" tab ~ "Provider Type" column to classify each service by
provider type. This aids group health plans and health insurance issuers in applying benefits to each item and service.
Provider Type
Diabetes Educator
Dietitian
Emergency Room
Ophthalmology
Pharmacy Retail
Podiatry
Primary
What providers are covered under this Provider Type and other notes:
Primary Care Physician or non-Specialist
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
The following are the categories to use on the "Scenario" tab ~ "Category" column to classify each item and service
so it rolls up to the same category in the Coverage Example label on the "Label and Assumptions" tab. This
facilitates consistency between the "Scenario" tab and Coverage Example label.
Category
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
What services are covered under this Category and other notes:
Includes all prescription drugs (generic, brand/preferred, non-preferred) which
are not administered in a hospital, physician's office or other facility. Note, this
category may also include over-the-counter drugs such as aspirin and other
pharmacy items.
Includes durable medical equipment, orthotics, prosthetics
Includes services by physicians and other providers.
Includes blood work
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
| File Type | application/pdf |
| Subject | Summary of Benefits and Coverage - Diabetes Scenario |
| Author | Center for Consumer Information and Insurance Oversight |
| File Modified | 2012-05-22 |
| File Created | 2012-05-22 |