Page 8 - Enrollment Guide

8

Health Plan Cost Comparison

This tool can help you estimate and compare your anticipated out-of-

pocket expenses for the High Deductible Plan with the Low Deductible
Plan.

Step 1: Enter how much you will be contributing toward your premium*
How much will you pay toward the plan premium?
(2016 monthly premium) x (12) =
* Refer to the cost of coverage on page 7.
High deductible Low deductible
$ $

(Annual Premium) (Annual Premium)
Step 2: Enter beneit details for the plan
What does the policy* require for
High deductible Low deductible
Deductible $ $
Out-of-pocket maximum $ $
Coinsurance amount (after meeting $ $
deductible)*
Step 3: Estimate your medical costs
How much will you pay toward doctor visits?
Consider the number of visits you anticipate for each family member in 2016, and
whether you’ll pay just a copayment or if you’ll be responsible for the complete
costs.
High deductible Low deductible
Family member 1 $ $
Family member 2 $ $
Family member 3 $ $
Self $ $
Other expenses (medical supplies, $ $
equipment, etc.)
Subtotal of medical costs $ $