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Calculators: Sample Page
Here is the total overview of your budget and the factors that contributed to these costs.
Background
1. Gender M F
2. Zip Code*
3. Birth Year*
4. Do you have: Type 1
Type 2
Gestational Diabetes
Pre-Diabetes
5. What insurance provider do you use?
6. Do you use a mail-order supplier? If yes, which one?
7. Do you test your blood sugar? Yes No
8. How many times a day do you test? / day
Monitors
9. Do you use a handheld blood glucose monitor (BGM)? Yes No
10. Do you use a continuous glucose monitor (CGM)? Yes No
11. How often do you change monitors? Every months
12. Do you buy your monitors or do you get them for free? Buy Free
13. What was the last out of pocket price you paid for your monitor? $
14. If you got any rebate on your monitors, how much was it? $
Test Strips
15. How often do you purchase test strips? Every months
16. What was the last price you paid for your test strips(after insurance coverage)? $
17. If you received a rebate on your test strips, how much was it? $
Sensors
18. If you use a CGM, how often do you purchase sensors? Every months
19. What was the last price you paid for your sensors (after insurance coverage)? $
20. If you received any rebate on your sensors, how much was it? $
Consumables
21. How often do you purchase associated consumables for your BGM or CGM (lancets, alcohol wipes, cleaning supplies etc.)? Every months
22. What was the last price you paid for consumables (with or without insurance coverage)? $
23. If you get any rebate on your consumables, how much is it? $
24. If you get any other diabetes care rebate(s), how much do you get? And for what? $
Providers
25. Which of the following professional care services do you use regularly and how often?
Health Care Provider Cost How often do you visit?
Physician (general PCP/specialist) $ Every months
Endocrinologist $ Every months
Diabetes Educator $ Every months
Nutritionist/Dietician $ Every months
Home Care Provider $ Every months
Podiatrist $ Every months
Ophthalmologist $ Every months
Other $ Every months
Other $ Every months
Other $ Every months
Oral Medications
26. Do you take any of the following drugs to manage your blood sugar?
Medication Cost How often do you refill it?
Fortamet® $ Every 1 3 months
Glucophage® $ Every 1 3 months
Glucophage XR® $ Every 1 3 months
Glumetza® $ Every 1 3 months
Riomet® $ Every 1 3 months
Metformin® $ Every 1 3 months
Actose® $ Every 1 3 months
Avandia® $ Every 1 3 months
Januvia® $ Every 1 3 months
Amaryl® $ Every 1 3 months
Diapride® $ Every 1 3 months
Do you use any additional non-diabetic medications to manage your health? (for example, aspirin, blood pressure med, other)
$ Every 1 3 months
What other medications do you take related to your diabetes care?
Other $ Every 1 3 months
Other $ Every 1 3 months
Needles and Syringes
27. If you use insulin, how often do you purchase needles and associated consumables? Every months
28. What was the last price you paid for needles (with or without insurance coverage)? $
29. If you get any rebate on your needles/syringes, how much is it? $
Insulin
30. Do you take any of the following types of injectible insulin to manage your blood sugar?
32. If you use insulin, how often do you purchase needles and associated consumables? Every months
33. What was the last out-of-pocket price you paid for needles and associated consumables? $
34. If you received any rebate on your needles/syringes , how much was it? $
35. Do you take any of the following types of injectible insulin to manage your blood sugar?
Medication Cost How often do you refill it?
Fast-acting
Humalog® $ Every 1 3 months
NovoLog® $ Every 1 3 months
Apidra® $ Every 1 3 months
ReliOn® / Novolin® Regular $ Every 1 3 months
Intermediate-acting
Novolin® NPH $ Every 1 3 months
Long-acting
LANTUS® $ Every 1 3 months
Levemir® $ Every 1 3 months
Non-insulin injectible
Byetta® $ Every 1 3 months
Symlin® $ Every 1 3 months
Pre-mixed
NovoLog® $ Every 1 3 months
Humalog® mix 50/50™ $ Every 1 3 months
Humalog® mix 75/25™ $ Every 1 3 months
Other
Other $ Every 1 3 months
Other $ Every 1 3 months
Other $ Every 1 3 months
36. If you received any rebate on your insulin , how much was it? $
31. If you get any rebate on your insulin, how much is it? $
Lab Tests
32. Which of the following laboratory tests do you use regularly and how often?
Lab Tests Cost How often do you get tested?
HbA1c $ Every 3 6 12 months
Urine Microalbumin $ Every 3 6 12 months
Lipid Profile $ Every 3 6 12 months
Other $ Every 3 6 12 months
Other $ Every 3 6 12 months
Other $ Every 3 6 12 months
Or What was the last combined cost for the laboratory tests selected above?
Combined Lab Tests $ Every 3 6 12 months
Nutritional Supplements
33. Do you use any of the following foods designed for people with diabetes?
Product Name Cost per Package Number of Packages Every Month(s)
Boost® Drinks $ Every months
Enterex® Drinks $ Every months
Glucerna™ Cereal $ Every months
Glucerna™ Shakes $ Every months
Glucerna™ Snacks or Meal Bars $ Every months
Glucoburst® Drinks $ Every months
Glucoburst® Gel $ Every months
Glucoburst® Tablets $ Every months
Other $ Every months
Other $ Every months
Other $ Every months
Vitamins & Minerals
34. Do you take any additional vitamins and minerals to manage your diabetes?
Vitamin/Mineral Cost per Bottle Frequency of bottle purchase
General MultiVitamin $ Every months
Vitamin E $ Every months
Vitamin C $ Every months
Vitamin B6 $ Every months
Vitamin B12 $ Every months
Biotin $ Every months
Niacin $ Every months
Chromium $ Every months
Manganese $ Every months
Magnesium $ Every months
Vanadium $ Every months
Potassium $ Every months
Zinc $ Every months
Coenzyme Q10 $ Every months
Inositol $ Every months
ALA and GLA $ Every months
Carnitine $ Every months
Taurine $ Every months
Other $ Every months
Other $ Every months
Other $ Every months
Based on your unique profile, Diabetes1.org has customized cost savings recommendations for you. Click here to read suggestions.
Your Total Annual Direct Cost of Managing Your Diabetes: $5760
© Body1, Inc. Aug, '17

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