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 |
Plan A |
Plan B |
Plan C |
Premiums |
-
|
-
|
-
|
Yearly deductible |
-
|
-
|
-
|
Benefit or services |
-
|
-
|
-
|
Annual maximum benefit |
-
|
-
|
-
|
Alcohol and drug abuse
|
|
|
|
Allergy testing or treatment |
-
|
-
|
-
|
Ambulance |
-
|
-
|
-
|
Chiropractic |
-
|
-
|
-
|
Durable medical equipment
(crutches, beds, etc.) |
-
|
-
|
-
|
Emergency care
|
-
|
-
|
-
|
Eye examinations
|
-
|
-
|
-
|
Hearing testing
|
-
|
-
|
-
|
Hospice care |
-
|
-
|
-
|
Immunizations |
-
|
-
|
-
|
Mammograms |
-
|
-
|
-
|
Maternity |
-
|
-
|
-
|
Mental health
|
-
|
-
|
-
|
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: |
-
|
-
|
-
|
