PEIA’s Face-to-Face (F2F) Diabetes Program requires active participation and Program compliance. In return, you will receive health information related to your diabetes and waived copayments for some of your diabetes-related prescription drugs and supplies, once your deductible has been met. You must use a retail pharmacy, NOT mail order, to receive the benefit of waived co-payments.

The program is limited to a lifetime maximum of two (2) years or two attempts. If you fail to complete the full two-year program in your first attempt, you may apply for a second attempt after a one-year waiting period. Second-attempt participants are eligible for a maximum of one year of F2F services, as long as they remain compliant with the program requirements. At completion of the program, you will graduate, will stop receiving waived copayments, and will have exhausted your lifetime benefit for the program. 

By agreeing to participate in this program you are authorizing the release of your medical and/or protected health information (PHI) as it relates to the diagnosis, care, and treatment of diabetes to PEIA and its contracted providers for the meaningful use of managing your participation in the program.

This is a voluntary program which uses email and phone calls as the primary methods of communication. Participants are required to provide a valid email address and phone number. It is your responsibility to supply PEIA with accurate and up-to-date contact information.

After acceptance into the F2F Diabetes Program you must:

• Submit your current Hemoglobin A1c (HbA1c) lab value to your F2F Diabetes Program provider at each visit. The HbA1c lab test must have been performed within the past 30 days at your first visit, and within the past 90 days at each quarterly visit throughout your enrollment. If you fail to provide the recent HbA1c result, your visit will be rescheduled.
• Contact your F2F Diabetes Program provider (the individual you select on your application -- not your primary care physician or regular medical provider), within the first 7 days of your F2F program effective date to schedule your first visit.

As a participant in the program, you, and your F2F Diabetes Program provider will develop an individual care plan where you understand and agree to:

• Commit time and effort to learn more about diabetes and how it affects your health.
• Become an active participant in improving your health.
• Attend regularly scheduled visits with your primary care physician (PCP) to manage your diabetes.
• Visit your F2F Diabetes Program provider monthly for the first three months, then quarterly throughout your enrollment in the program. It is your responsibility to ensure all required visits are scheduled and attended.
• After one year of participation, if your HbA1c lab value is greater than 8.0 or has not decreased by 1.0 percentage point, (example:  11.3 to 10.3) you will be disenrolled for non-compliance.  If you are disenrolled for a non-compliant HbA1C, you or your treating physician may submit a written appeal documenting the medical reason the improvement cannot be achieved.
• Notify your F2F Diabetes Program provider at least 24 hours in advance if you need to reschedule your visit, except in the case of an emergency. Please keep in mind that the required visit timeframes must still be met even in the event of rescheduling the appointment.
• Provide self-monitored glucose values to your F2F Diabetes Program provider at each visit

I understand the requirements to participate in the PEIA Face-to-Face (F2F) Diabetes Program. I agree to follow the above requirements 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 PEIA PPB Plan benefits. I also understand and agree that to coordinate the program, PEIA staff, my F2F Diabetes Program provider and my other healthcare providers will share information, and that if I change F2F Diabetes Program 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.