Health plan comparison worksheet

Under each plan you are comparing, note whether the benefit is offered and the required co-payment or deductible for the benefit.
Benefit or services Plan A Plan B Plan C
Premiums      
Yearly deductible      
Benefit or services      
Annual maximum benefit      
Acupuncture      
Alcohol and drug abuse
  • Inpatient
  • Outpatient
     
Allergy testing or treatment      
Ambulance      
Chiropractic      
Durable medical equipment
(crutches, beds, etc.)
     
Emergency care
  • In area
  • Out-of-area
     
Eye examinations
  • Eyeglasses
  • Contacts
     
Hearing testing
  • Hearing aids
     
Home health care      
Hospice care      
Immunizations      
Infertility treatment      
Mammograms      
Maternity      
Mental health
  • Inpatient
  • Outpatient
     
Occupational therapy      
Organ transplants      
Pap test      
Physician office visits      
Physical therapy      
Plastic/reconstructive surgery      
Prescription drugs
  • Generic
  • Formulary
  • Nonformulary
     
Skilled nursing facility      
Speech therapy      
Well child care      
Other services      

Other Misc Services