Common use of Diabetes Clause in Contracts

Diabetes. The following services related to diabetes are covered with $0 Out-of-Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist (diabetes specialist) for consultation and management of diabetes • Office visits to a Podiatrist (foot specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery Program: up to 150 every 30 days or 450 every 90 days at $0 Out-of-Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care center, have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. Insulin pumps, continuous glucose monitors and associated supplies are considered Durable Medical Equipment (DME); they are not covered under the CISP benefit and they are subject to applicable Plan cost-sharing terms. SAMPLE

Diabetes. The following services related to diabetes are covered with $0 Out-of-Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist (diabetes specialist) for consultation and management of diabetes • Office visits to a Podiatrist (foot specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) 12 visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery Program: up to 150 every 30 days or 450 every 90 days at $0 Out-of-Pocket Cost • Continuous Glucose Monitoring products listed on the formulary as CISP and dispensed through our Home Delivery Program up to an 84-day supply at $0 Out-of-Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care center, have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. Insulin pumps, continuous glucose monitors monitoring (CGM) systems (other than the CGM systems noted on formulary as CISP) and associated supplies are considered Durable Medical Equipment (DME); they are not covered under the CISP benefit and they are subject to applicable Plan cost-sharing terms. SAMPLE.

Diabetes. The following services related to diabetes are covered with $0 Out-of-Out - of - Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist Endocrinolog ist (diabetes specialist) for consultation and management of diabetes • Office visits to t o a Podiatrist Podiatr ist (foot foo t specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Optometrist/ Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery ProgramProgram : up to 150 every 30 days or 450 every 90 days at $0 Out-of-Out - of- Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care centercenter , have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Out - of- Pocket Costs as outlined in your Schedule of BenefitsBenefits . Insulin pumpspumps , continuous glucose monitors and associated supplies are considered Durable Medical Equipment (DME)) ; they are not covered under the CISP benefit and they are subject to applicable Plan cost-cost - sharing terms. SAMPLEterms .

Diabetes. The following services related to diabetes are covered with $0 Out-of-Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist (diabetes specialist) for consultation and management of diabetes • Office visits to a Podiatrist (foot specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery Program: up to 150 every 30 days or 450 every 90 days at $0 Out-of-Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care center, have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. Insulin pumps, continuous glucose monitors and associated supplies are considered Durable Medical Equipment (DME); they are not covered under the CISP benefit and they are subject to applicable Plan cost-sharing terms. SAMPLE.

Diabetes. The following services related to diabetes are covered with $0 Out-of-Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): SAMPLE • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist (diabetes specialist) for consultation and management of diabetes • Office visits to a Podiatrist (foot specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery Program: up to 150 every 30 days or 450 every 90 days at $0 Out-of-Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care center, have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Pocket Costs as outlined in your Schedule of Benefits. Insulin pumps, continuous glucose monitors and associated supplies are considered Durable Medical Equipment (DME); they are not covered under the CISP benefit and they are subject to applicable Plan cost-sharing terms. SAMPLE.

Diabetes. The following services related to diabetes are covered with $0 Out-of-Pocket Out‐of‐Pocket Cost when linked to a primary diagnosis of diabetes and performed by a Network Provider (unless otherwise noted): • Office visits to a Primary Care Provider for routine management of diabetes • Office visits to an Endocrinologist (diabetes specialist) for consultation and management of diabetes • Office visits to a Podiatrist (foot specialist) for consultation for routine diabetic foot care • Palliative Care Conversations (chronic condition treatment preferences) with a Primary Care Provider or Endocrinologist • Nutritional counseling up to six (6) visits per year • Diabetes education (with certified diabetes educator) • Diabetic (dilated) eye exam performed by Optometrist/Ophthalmologist will be covered once a year • Targeted laboratory test for the routine management of diabetes • One glucometer each year as specified on the formulary and dispensed through our Home Delivery Program • Glucose test strips listed on formulary and dispensed through our Home Delivery Program: up to 150 every 30 days or 450 every 90 days at $0 Out-of-Pocket Out‐of‐Pocket Cost Please note, if you have complications from diabetes and use an emergency department or urgent care center, have a Hospital stay, or get treated for heart or kidney problems, the usual and customary Plan costs for these services apply, and will be subject to standard Out-of-Pocket Out‐of‐Pocket Costs as outlined in your Schedule of Benefits. Insulin pumps, continuous glucose monitors and associated supplies are considered Durable Medical Equipment (DME); they are not covered under the CISP benefit and they are subject to applicable Plan cost-sharing cost‐sharing terms. SAMPLE.