Managing Type 2 Diabetes

Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the

Managing Type 2 Diabetes

Scenario tab.

Sample Care Costs
Professional Services: Primary Care
Professional Services: Specialist
Diagnostic Services: Laboratory
Prescription Drugs: Generic
Prescription Drugs: Branded
Over-the-counter Drugs
Preventive Services & Vaccines
Medical Supplies
Total (unrounded)

$791
$273
$134
$676
$3,582
$55
$150
$1,728
$7,389

Assumptions
The following are assumptions that all group health plans and health insurance issuers must use for this scenario.
Standard Assumptions
These assumptions are standard across all scenarios.
Costs do not include premiums.
Condition was not excluded as a pre-existing condition.
There are no other medical expenses for any member covered under the plan or policy.
All care is in-network and considered first tier (or the tier associated with the lowest level of cost sharing), for those products that incorporate tiered provider networks.
No out-of-network charges or any other variation in Sample Care Costs.
All services occur in same policy period.
All prior authorizations were obtained.
All services were deemed medically necessary.
All costs (allowed amount, sample care costs, member costs) greater than $100 are rounded to the nearest hundredth.
All costs (allowed amount, sample care costs, member costs) less than $100 are rounded to the nearest tenth.
All medications are covered as generic equivalents if available.
If the plan has a wellness program that varies the deductibles, copayments, coinsurance, or coverage for any of the services listed in a treatment scenario, the plan or issuer
must complete the calculations for that treatment scenario assuming that the patient is NOT participating in the wellness program.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

Medical Condition:

Managing Type 2 Diabetes

Note: Services on this tab are listed individually for classification and pricing purposes to facilitate the population of the “Sample care costs” section. HHS specifies the Category in order to roll up costs into
that category in the "Sample care costs" section so that those costs are uniform across all group health plans and health insurance issuers. However, some plans or issuers may classify an item or service
under another category. The plan or issuer should apply its cost sharing and benefit features for each plan or policy in order to complete the “You pay” section, but must leave as is the "Sample care costs"
section. Examples of cost sharing and benefit features include, but are not limited to:
• Payment of services based on the location such as inpatient, outpatient, or office; and
• Payment of items as prescription drugs vs. medical equipment.
Explanation of Scenario:
Total – the sum of allowed amounts for the listed items and services, which is cross-referenced in the "Label and Assumptions" tab, where it is rounded.
Date of Service – includes the day and month of service so plans and issuers understand the order in which items or services are rendered.
ICD-9 Diagnosis Code – includes the ICD-9 code for each item or service.
ICD-10 Diagnosis Code – includes the ICD-10 code for each item or service.
CPT, HCPCS or Other Billing Code – includes medical codes for each item or service. Over-the-counter medications are listed as OTC.
Provider Type – includes one of the types listed on the "Provider Types" tab to classify each item or service by provider.
Category – includes one of the categories listed on the "Categories" tab to classify each item or service so it rolls up into the same category in the "Label and Assumptions" tab.
Description – includes the short form descriptor for a CPT code, or an appropriate descriptor for a non-CPT billing code.
Allowed Amount – includes an estimated national average allowed amount for each item or service, which plans or issuers must use to calculate cost sharing.
CPT copyright 2010 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Totals:
ICD-9
ICD-10
Date of
Diagnosis
Diagnosis
CPT©, HCPCS, or Other Billing Code
Service
Code
Code

$7,389.29
Provider Type

Category

Description

Allowed
Amount

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885014201

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancing Device

$16.12

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885044801

Pharmacy Retail

Medical Supplies

OneTouch Ultra 2 Blood Glucose
Meter Kit

$56.90

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

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

$125.26

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885041601

Pharmacy Retail

Medical Supplies

OneTouch Ultra Control Solution (2
vials/box)

$5.07

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

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

$4.27

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

2803101

Pharmacy Retail

Prescription Drugs: Generic

Glucagon Emergency Kit

$246.17

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

60505257909

Pharmacy Retail

Prescription Drugs: Generic

Atorvastatin 20 MG tablet 90 CT

$25.88

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

82947

Primary

Diagnostic Services: Laboratory

Assay Glucose Blood Quant

$5.73

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

82570

Primary

Diagnostic Services: Laboratory

Assay of Urine Creatinine

$5.79

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

80053

Primary

Diagnostic Services: Laboratory

Comprehen Metabolic Panel

$14.53

03-Jan

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

83036

Primary

Diagnostic Services: Laboratory

Glycosylated Hemoglobin Test

$10.85

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

80061

Primary

Diagnostic Services: Laboratory

Lipid panel

$14.42

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

82043

Primary

Diagnostic Services: Laboratory

Microalbumin Quantitative

$6.32

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

80069

Primary

Diagnostic Services: Laboratory

Renal Function Panel

$11.63

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

36415

Primary

Diagnostic Services: Laboratory

Routine Venipuncture

$4.17

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

81003

Primary

Diagnostic Services: Laboratory

Urinalysis Auto W/O Scope

$3.09

03-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

99214

Primary

Professional Services: Primary
Care

Office/Outpatient Visit Est

$107.87

04-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

98960

Diabetes Educator

Professional Services: Primary
Care

Self-mgmt educ & train 1 pt

$99.90

04-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

97803

Dietician

Professional Services: Primary
Care

Med Nutrition Indiv Subseq

$80.00

06-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

99204

Podiatry

Professional Services: Specialist

Office/Outpatient Visit New

$165.00

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

$108.24

07-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

92014

Ophthalmology

31-Jan

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

02-Feb

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

02-Feb

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

02-Feb

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

02-Feb

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

22-Feb

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

22-Feb

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

53885024510

Pharmacy Retail

Medical Supplies

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

$125.26

28-Feb

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

04-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

04-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

04-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

04-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

28-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

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

$4.27

28-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

28-Mar

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

99214

Primary

Professional Services: Primary
Care

Office/Outpatient Visit Est

$107.87

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

60505257909

Pharmacy Retail

Prescription Drugs: Generic

Atorvastatin 20 MG tablet 90 CT

$25.88

03-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

83036

Primary

Diagnostic Services: Laboratory

Glycosylated Hemoglobin Test

$10.85

13-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

13-Apr

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

53885024510

Pharmacy Retail

Medical Supplies

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

$125.26

25-Apr

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

03-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

03-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

03-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

03-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

23-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

23-May

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

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

$125.26

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

02-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

20-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

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

$4.27

20-Jun

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

27-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

82947

Primary

Diagnostic Services: Laboratory

Assay Glucose Blood Quant

$5.73

27-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

83036

Primary

Diagnostic Services: Laboratory

Glycosylated Hemoglobin Test

$10.85

27-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

80069

Primary

Diagnostic Services: Laboratory

Renal Function Panel

$11.63

27-Jun

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

36415

Primary

Diagnostic Services: Laboratory

Routine Venipuncture

$4.17

27-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

81003

Primary

Diagnostic Services: Laboratory

Urinalysis Auto W/O Scope

$3.09

27-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

99214

Primary

Professional Services: Primary
Care

Office/Outpatient Visit Est

$107.87

28-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

98960

Diabetes Educator

Professional Services: Primary
Care

Self-mgmt educ & train 1 pt

$99.90

28-Jun

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

97803

Dietician

Professional Services: Primary
Care

Med Nutrition Indiv Subseq

$80.00

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885041601

Pharmacy Retail

Medical Supplies

OneTouch Ultra Control Solution (2
vials/box)

$5.07

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

02-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

60505257909

Pharmacy Retail

Prescription Drugs: Generic

Atorvastatin 20 MG tablet 90 CT

$25.88

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

18-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

22-Jul

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

01-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

01-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

01-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

01-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

15-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

16-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

31-Aug

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

OTC

Pharmacy Retail

Over-the-counter Drugs

31-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

31-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

31-Aug

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

10-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

10-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

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

$125.26

12-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

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

$4.27

12-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

26-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

99214

Primary

Professional Services: Primary
Care

Office/Outpatient Visit Est

$107.87

30-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

OneTouch Ultra Blue Test Strips (Rx box of 100) [usage = 2 strips/day; 60
per month]
Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

OneTouch Ultra Blue Test Strips (Rx box of 100) [usage = 2 strips/day; 60
per month]
Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$275.51

$125.26

$2.61

$125.26

$2.61

30-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

30-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

30-Sep

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

03-Oct

V03.82

Z23

90472

Primary

Preventive Services & Vaccines

Immunization admin each add

$14.98

03-Oct

V03.82

Z23

90471

Primary

Preventive Services & Vaccines

Immunization Admin

$23.00

03-Oct

V03.82

Z23

90669

Primary

Preventive Services & Vaccines

Pneumococcal vacc 7 val im

$97.86

03-Oct

V04.81

Z23

90656

Primary

Preventive Services & Vaccines

Flu Vaccine No Preserv 3 & >

$14.27

03-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

60505257909

Pharmacy Retail

Prescription Drugs: Generic

Atorvastatin 20 MG tablet 90 CT

$25.88

03-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

83036

Primary

Diagnostic Services: Laboratory

Glycosylated Hemoglobin Test

$10.85

10-Oct

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

30-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

30-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

30-Oct

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

30-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

30-Oct

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

07-Nov

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

29-Nov

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$2.61

29-Nov

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

29-Nov

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

29-Nov

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

05-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

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

$4.27

05-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

88222033

Pharmacy Retail

Prescription Drugs: Branded

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

$275.51

19-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885039310

Pharmacy Retail

Medical Supplies

OneTouch Delica Lancets (100 per
box) [usage = 60 lancets per month]

$10.38

19-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885024510

Pharmacy Retail

Medical Supplies

29-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

OTC

Pharmacy Retail

Over-the-counter Drugs

29-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

8290328279

Pharmacy Retail

Medical Supplies

BD Ultrafine Insulin Syringes / 30G/
0.5cc [usage = 30 syringes per month]

$42.66

29-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

53885041601

Pharmacy Retail

Medical Supplies

OneTouch Ultra Control Solution (2
vials/box)

$5.07

29-Dec

250.00, V58.66, E119.00, Z7982,
Z794
V58.67

93104901

Pharmacy Retail

Prescription Drugs: Generic

METFORMIN HCL 850 MG TABLET

$9.19

29-Dec

250.00, V58.66, E119.00, Z7982,
V58.67
Z794

93743801

Pharmacy Retail

Prescription Drugs: Generic

Ramipril 10mg (Rx) [1 QD; #30
pills/month]

$15.92

OneTouch Ultra Blue Test Strips (Rx box of 100) [usage = 2 strips/day; 60
per month]
Alcohol swabs (OTC - box of 100)
[usage = 3 wipes/day; 90
wipes/month]

$125.26

$2.61

** 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.)

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
Pharmacy Retail
Primary
Diabetes Educator
Diatician
Podiatry
Ophthalmology

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
Over-the-counter Drugs
Medical Supplies
Prescription Drugs: Generic
Prescription Drugs: Branded
Diagnostic Services: Laboratory
Professional Services: Primary Care
Professional Services: Specialist
Preventive Services & Vaccines

What services are covered under this Category and other notes:

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146