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Health plan comparison worksheet

Under each plan you are comparing, note whether the benefit is offered and what your out-of-pocket expenses would be (co-payment and/or co-insurance).

Benefit or services

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Plan A

Plan B

Plan C

Premiums

 
 
 
 
 
 

Yearly deductible

 
 
 
 
 
 

Benefit or services

 
 
 
 
 
 

Annual maximum benefit

 
 
 
 
 
 

Alcohol and drug abuse

  • Inpatient
  • Outpatient

 

 

 

 

 

 

Allergy testing or treatment

 
 
 
 
 
 

Ambulance

 
 
 
 
 
 

Chiropractic

 
 
 
 
 
 

Durable medical equipment
(crutches, beds, etc.)

 
 
 
 
 
 

Emergency care

  • In area
  • Out-of-area
 
 
 
 
 
 

Eye examinations

  • Eyeglasses
  • Contacts
 
 
 
 
 
 

Hearing testing

  • Hearing aids
 
 
 
 
 
 

Hospice care

 
 
 
 
 
 

Immunizations

 
 
 
 
 
 

Mammograms

 
 
 
 
 
 

Maternity

 
 
 
 
 
 

Mental health

  • Inpatient
  • Outpatient
 
 
 
 
 
 

Occupational therapy

 
 
 
 
 
 

Pap test

 
 
 
 
 
 

Physician office visits

 
 
 
 
 
 

Physical therapy

 
 
 
 
 
 

Plastic/reconstructive surgery

 
 
 
 
 
 

Prescription drugs

  • Generic
  • Formulary
  • Nonformulary
 
 
 
 
 
 

Skilled nursing facility

 
 
 
 
 
 

Well child care

 
 
 
 
 
 

Other:

 
 
 

Other:

 
 
 

Other:

 
 
 

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