Plan A
Plan B
Plan C
Your monthly contribution
$
$
$
Plan Information
(Fill in the coverage information in this section to compare the plans.)
Plan Type
Deductible
Copay
Deductible
Copay
Deductible
Copay
Out of pocket maximum
$
$
$
Deductible level (In Network)
$
$
$
Your employer's HRA/HSA contribution
$
$
$
Coverage level after deductible
%
%
%
Office visits copayment
$
$
$
Generic Prescription copayment/coinsurance
$
%
$
%
$
%
Brand Prescription copayment/coinsurance
$
%
$
%
$
%
Expenses
(Fill in the expense information in this section.)
Number of office visits per year
Estimated total annual medical expenses (excluding pharmacy costs)
$
$
$
Number of generic prescriptions per year
Number of brand prescriptions per year
Estimated total annual pharmacy expenses
$
$
$
Comparison Results
The minimum you pay is your monthly premium contribution and the maximum you would pay is your monthly premium contribution plus in-network out-of-pocket maximum. If you seek out-of-network care, expenses will be higher.
The minimum it could cost you
$
$
$
The maximum it could cost you
$
$
$
Total Expense
$
$
$
Remaining HRA/HSA funds
$
$
$
Your estimated out of pocket expense
$
$
$