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Consumers: Health Plan Comparison and Checklist

The checklist form below is created to assist you in comparing health plans.  On this form, we included the suggested items that we think consumers should consider when shopping for a health plan.  

The form and the completed sample forms are created in Adobe Acrobat format.

Health Plan Comparison (PDF) -  an example of a plan coverage between multiple companies.

In vs. Out of Network Comparison (PDF)- an example of a costs comparison between In-Network and Out-of-Network provider.

Health Plan Checklist Form

Use this checklist when comparing plans. Are things that are important to you covered? If covered, what are the limitations on the coverage? How much is paid for by the insurance and how much do I have to pay out-of-pocket? Refer to the "filled-in checklist" (PDF) as a guide when completing your checklist form. 

Interactive Checklist Form is also available in pdf format.

BENEFIT COVERED OR IN EFFECT?
(YES OR NO)
HOW MUCH IS COVERED? YOU PAY
Office visits       
Physical exams      
Diagnostics (lab, medical procedures)      
Emergency room visits      
Cardiac/advanced procedures      
Hospitalization      
Preventive care      
Pre-existing conditions      
Well-child exams      
Immunization      
Maternity care      
Drug benefits      
Mental health coverage      
Network discount applies to deductible?      
Maximum out-of-pocket limits?      
Limitations on reimbursement for certain procedures?      

 

COSTS AMOUNT
Premium  
Office visit co-pay  
Prescription drug co-pay (generic, name brand)  
Emergency room co-pay  
Coinsurance (you pay)  
Deductible  


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