Face to Face Diabetes Program

PARTICIPANT AGREEMENT

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.

You and your provider will develop an individual care plan. You will be required to:

  • commit time and effort in order to learn more about diabetes and how it affects your health;
  • follow recommendations from the F2F program and nationally recognized organizations to keep you healthy;
  • meet with your F2F provider according to F2F requirements; and
  • submit your most recent Hemoglobin A1c to your F2F provider at each visit per the American Diabetes Association guidelines

You must attend F2F provider visits once a month for the first three months, quarterly through the end of the first year of enrollment, then based on your current Hemoglobin A1C value, twice per year. If your Hemoglobin A1C value is 7 or higher, you may be seen up to four times per year.

After twelve months of enrollment, to continue participation, you must submit to your F2F provider your Hemoglobin A1c value obtained within the last six months. If your Hemoglobin A1c is 8 or less, you will be permitted to remain in the program and receive waived co-payments. If your Hb A1c is greater than 8, you will be dis-enrolled from F2F, unless you provide a report from your health care provider documenting a medical reason prohibiting you from achieving this goal.

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

  1. If you are not contacted by your F2F provider within the first month of enrollment, it is your responsibility to contact the F2F provider to schedule an initial appointment.
  2. If the F2F provider does not schedule your required appointments, it is your responsibility to contact the F2F provider to be seen as required by the program.
  3. If you are still not being seen by your F2F provider, it is your responsibility to contact PEIA to inform staff that you are not being seen regularly.
  4. If you must cancel or re-schedule an appointment you must provide notice to the F2F provider at least 24 hours in advance, except in the case of an emergency.
  5. If you miss two F2F appointments without notification and documented cause to your F2F provider, you will be dis-enrolled from the Program.

It is a shared responsibility between the F2F provider and participant to ensure all required visits are attended and documented. To request a transfer to another participating F2F provider, please send the request in writing via e-mail, fax or mail. You and the new F2F provider will receive confirmation of the transfer.

I understand the requirements to participate in the 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, 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.

   
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