Summary of Benefits and Coverage

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Overview

Label and Assumptions
Scenario
Provider Types
Categories

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Sheet 1: Label and Assumptions

Managing type 2 diabetes (routine maintenance of a well-controlled condition)		Instructions to Plans and Issuers: Do not modify this tab. The numbers shown here roll up from the Scenario tab.
Sample care costs:
Prescriptions	$2,900
Medical Equipment and Supplies	$1,300
Office Visits and Procedures	$700
Education	$300
Laboratory tests	$100
Vaccines, other preventive	$100
Total	$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

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Sheet 2: Scenario

Medical Condition:						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. 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
Totals:							$5,489.63
Date of Service	Diagnosis Code (ICD-9)	Diagnosis Code (ICD-10)	CPT©, HCPCS, or Other Billing Code	Provider Type	Category	Descriptor	Allowed Amount	Notes
3-Jan	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]	$3.00
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
3-Jan	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
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885014201	Pharmacy Retail	Medical equipment and supplies	OneTouch Delica Lancing Device	$18.00
3-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	$66.00
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
3-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
3-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
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	00002803101	Pharmacy Retail	Pharmacy	Glucagon Emergency Kit	$153.00
3-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]	$119.20
3-Jan	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
3-Jan	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
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	82947	Primary	Laboratory tests	Assay Glucose Blood Quant	$6.43
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	82570	Primary	Laboratory tests	Assay of Urine Creatinine	$7.17
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	80053	Primary	Laboratory tests	Comprehen Metabolic Panel	$18.13
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	83036	Primary	Laboratory tests	Glycosylated Hemoglobin Test	$14.07
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	80061	Primary	Laboratory tests	Lipid panel	$19.23
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	82043	Primary	Laboratory tests	Microalbumin Quantitative	$8.31
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	80069	Primary	Laboratory tests	Renal Function Panel	$14.30
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	36415	Primary	Laboratory tests	Routine Venipuncture	$4.13
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	81003	Primary	Laboratory tests	Urinalysis Auto W/O Scope	$3.18
3-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99214	Primary	Office visits & procedures	Office/Outpatient Visit Est	$102.47
4-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	98960	Diabetes Educator	Education	Self-mgmt educ & train 1 pt	$80.53
4-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	97803	Dietician	Education	Med Nutrition Indiv Subseq	$63.13
6-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99204	Podiatry	Office visits & procedures	Office/Outpatient Visit New	$157.61	Annual foot exam
7-Jan	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99204	Ophthalmology	Office visits & procedures	Office/Outpatient Visit New	$157.61	Annual eye exam
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]	$119.20
2-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]	$3.00
2-Feb	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
2-Feb	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
2-Feb	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
22-Feb	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
22-Feb	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
28-Feb	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]	$119.20
4-Mar	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]	$3.00
4-Mar	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
4-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
4-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
28-Mar	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]	$119.20
28-Mar	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99214	Primary	Office visits & procedures	Office/Outpatient Visit Est	$102.47
3-Apr	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]	$3.00
3-Apr	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
3-Apr	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
3-Apr	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
13-Apr	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
13-Apr	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
25-Apr	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]	$119.20
3-May	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]	$3.00
3-May	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
3-May	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
3-May	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
23-Apr	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
23-May	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]	$119.20
2-Jun	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]	$3.00
2-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
2-Jun	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
2-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
2-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
2-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
20-Jun	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]	$119.20
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	82947	Primary	Laboratory tests	Assay Glucose Blood Quant	$6.43
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	83036	Primary	Laboratory tests	Glycosylated Hemoglobin Test	$14.07
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	80069	Primary	Laboratory tests	Renal Function Panel	$14.30
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	36415	Primary	Laboratory tests	Routine Venipuncture	$4.13
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	81003	Primary	Laboratory tests	Urinalysis Auto W/O Scope	$3.18
27-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99214	Primary	Office visits & procedures	Office/Outpatient Visit Est	$102.47
28-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	98960	Diabetes Educator	Education	Self-mgmt educ & train 1 pt	$80.53
28-Jun	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	97803	Dietician	Education	Med Nutrition Indiv Subseq	$63.13
2-Jul	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]	$3.00
2-Jul	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
2-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
2-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
2-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
18-Jul	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]	$119.20
22-Jul	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
1-Aug	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]	$3.00
1-Aug	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
1-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
1-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
15-Aug	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]	$119.20
16-Aug	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
31-Aug	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]	$3.00
31-Aug	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
31-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
31-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
10-Sep	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
10-Sep	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
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
12-Sep	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]	$119.20
26-Sep	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	99214	Primary	Office visits & procedures	Office/Outpatient Visit Est	$102.47
30-Sep	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]	$3.00
30-Sep	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
30-Sep	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-Sep	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
3-Oct	V03.82	Z23	90472	Primary	Vaccines, other preventive	Immunization admin each add	$13.44
3-Oct	V03.82	Z23	90471	Primary	Vaccines, other preventive	Immunization Admin ADMIN	$13.44
3-Oct	V03.82	Z23	90669	Primary	Vaccines, other preventive	Pneumococcal vacc 7 val im	$98.22
3-Oct	V04.81	Z23	90656	Primary	Vaccines, other preventive	Flu Vaccine No Preserv 3 & >	$15.04
10-Oct	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]	$119.20
30-Oct	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]	$3.00
30-Oct	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
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]	$9.00
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
7-Nov	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]	$119.20
29-Nov	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]	$3.00
29-Nov	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
29-Nov	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-Nov	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
5-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
5-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]	$119.20
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
19-Dec	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	53885024510	Pharmacy Retail	Medical equipment and supplies	OneTouch Ultra Blue Test Strips (Rx - box of 100) [usage = 2 strips/day; 60 per month]	$123.60
29-Dec	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]	$3.00
29-Dec	250.00, V58.66, V58.67	E11.9, Z79.82, Z79.4	08290328279	Pharmacy Retail	Medical equipment and supplies	BD Ultrafine Insulin Syringes / 30G/ 0.5cc [usage = 30 syringes per month]	$8.40
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

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Sheet 3: Provider Types

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	What providers are covered under this Provider Type and other notes:
Diabetes Educator
Dietitian
Emergency Room
Ophthalmology
Pharmacy Retail
Podiatry
Primary	Primary Care Physician or non-Specialist
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146

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Sheet 4: Categories

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	What services are covered under this Category and other notes:
Prescriptions	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.
Medical Equipment and Supplies	Includes durable medical equipment, orthotics, prosthetics
Office Visits and Procedures	Includes services by physicians and other providers.
Education
Laboratory tests	Includes blood work
Vaccines, other preventive
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146