Page 9 - Enrollment Guide

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Step 4: Estimate your prescription drug costs
How much will you pay toward prescription drug costs?
Consider the amount you expect to pay for prescription drugs 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 $ $
All additional family members $ $
Subtotal of prescription drug $ $
costs
Step 5: Compare your results
Based on the estimates you provided above, here are the total out-of-pocket
expenses you can anticipate for these plans.
Estimated Costs for Estimated Costs for
High Deductible 1 Low Deductible 2

Your estimated costs (Annually) (Annually)
$ $
Less company contribution to the $ 0
HSA—$
(annual cost)÷(# of pay periods)= Per Pay Period Per Pay Period
$ $
Besides offering savings on your premium, a High Deductible Plan can offer other
beneits when paired with a Health Savings Account. See details of the HSA on page
20.

Benefit Guide 2016