Medical Expenses Worksheet
Estimating your out-of-pocket costs and calculating your annual deductions is a critical step in deciding which medical plan best suits you and your family's needs. Please begin by answering the initial 7 questions at the top. You will then see information populate throughout the remainder of the worksheet to help you determine which plan is the most cost effective, based on the most common employee expenses. This is only for estimating purposes and only assumes in-network expenses are incurred. Doctor's visits and prescription prices may vary. This does not take into account any hospital, urgent care, x-rays and other medical expenses you may incur throughout the year. Please see the Plan Summary for more details.
| Questions to consider | |
|---|---|
| Which coverage level will you be choosing? | |
| How many sick visits are you anticipating to your PCP? | |
| How many visits are you anticipating to a see specialist? | |
| How many generic prescriptions do you plan on filling? | |
| How many brand prescription do you plan on filling? | |
| How many maintenance prescriptions do you plan on filling? | |
| ChoicePlus HSA | ChoicePlus Base | ChoicePlus A | |
|---|---|---|---|
| Annual Employer Cost 1 | |||
| Annual Employee Contributions 1 | |||
| Annual Employer HSA Contribution 1 |
| Preventive Care Visits | |||
| Sick Visits to PCP | |||
| Specialist Visits | |||
| ‡ Copays go towards Out of Pocket Maximum, not the deductible. | |||
| Prescriptions - Generic 2 | |||
| Prescriptions - Brand 2 | |||
| Prescriptions - Preventive 2† | |||
| †Preventive drugs for the Base and A plans must be supplied through Caremark mail-order service, CVS Pharmacy, or Target Store. This assumes a 90-day supply of a generic prescription for $30. | |||
| Subtotal of expenses towards deductible or out-of-pocket maximum: | Expenses calculated here do not contribute towards your deductible. See Plan Documents for expenses that contribute to your deductible. | ||
|---|---|---|---|
| Deductible | |||
| Total of expenses after deductible is met: | Expenses calculated here do not contribute towards your deductible. See Plan Documents for expenses that contribute to your deductible. | ||
| Coinsurance cost: | Expenses calculated here aren't applicable for coinsurance. See Plan Documents for expenses that coinsurance will apply to after the deductible has been met. Coinsurance for the plans are as follows: ChoicePlus Base: 80% for In-Network / 60% for Out-of-Network ChoicePlus A: 90% for In-Network / 60% Out-of-Network |
||
| Out of Pocket Maximum | |||
| Prescription Out of Pocket Maximum | |||
| Total: Expenses/or Deductible + Copays + Coinsurance (if applicable) + Annual Employee contribution | |||
|---|---|---|---|
| Less Employer Contribution to HSA | |||
| Total: Expenses/or Deductible + Copays + Coinsurance (if applicable) + Annual Employee contribution |