PEIA’s Face-to-Face Diabetes Program requires active participation and Program compliance. In return, you will receive health information related to this Program. You will also receive cost savings through waived co-payments for some of your diabetes prescription drugs, once your deductible has been met. Participants must use a retail pharmacy to receive the benefit of waived co-payments. Participants who use mail order will not be eligible for the waived copayments.By agreeing to participate in this program you are authorizing the release of your medical and/or protected health information as it relates to the diagnosis, care, and treatment of diabetes to the PEIA F2F Diabetes Program and its contracted providers for the meaningful use of managing your participation in the program.

Furthermore, this is a voluntary program which uses email, phone calls and texts as the primary methods of communication, valid email addresses and phone numbers are required for participation.

As a participant in this program, you agree to perform an at-home fingerstick Hemoglobin A1C test upon your initial enrollment and then quarterly throughout your participation in the program. This test will be provided by PEIA through a contracted provider at no cost to you. The test will be mailed to your home and can be performed by you. Completion and return of this test in a timely manner are your responsibility and a requirement for continued participation.

As a participant in the program, you, and your Face-to-Face provider (this provider, who has been certified to offer education and coaching to individuals with diabetes, is different from your primary care physician or regular medical provider.) will develop an individual care plan where you understand and agree to:

• Commit time and effort in order to learn more about diabetes and how it affects your health.
• Become an active participant in improving your health.
• Perform the at-home fingerstick tests and return the test to the third-party vendor within 14 days from the day it was sent.
• Provide your most recent (within 90 days) Hemoglobin A1c (HbA1c) lab value received from the fingerstick tests to the F2F provider at the initial visit and every quarterly visit thereafter. If you do not provide these results your visit will be rescheduled.
• Attend regularly scheduled visits with their F2F provider and physician. Participation outline of this requirement is to attend F2F provider visits once a month for the first three months, then quarterly throughout your enrollment in the program.
• After one year of participation your HbA1c lab value will be evaluated. To remain compliant with the program, if your HbA1c lab value is greater than 8.0 or has not decreased by 1.0 point, (example 11.3 to 10.3)  you will be disenrolled. If you are disenrolled from the program, you, or your treating physician on your behalf, may submit an appeal validating the medical reason why the improvement cannot be achieved.
• Notify your F2F provider at least 24 hours in advance for re-scheduling of a visit.
• Provide self-glucose monitoring values to the provider at each visit.

Regarding your F2F provider visits, you are responsible for the following:

• Contact the provider within 7 days of your effective date to schedule the first visit.
• The first visit must be conducted within 30 days of your effective date.

It is the responsibility of the participant to ensure all required visits are scheduled and attended.

I understand the requirements to participate in the PEIA Face-to-Face Diabetes Program. I agree to follow the above policy and understand that my failure to comply will result in my dis-enrollment from the Program. I understand that being dis-enrolled from this Program will not affect any other PPB Plan benefits. I also understand and agree that to coordinate the Program, PEIA, its contracted providers, my F2F provider and my other health care providers will frequently share information and that if I change providers, my information will be shared with my new provider. The information I am required to provide, as a condition of participation, will only be used and disclosed for purposes related to this Program.