Health Plan Comparison Sheet SERVICE AND COST Emergency Room Urgent Care Surgery HEALTH CHOICE $25 co-pay In Network: $10 co-pay; 100% for initial exam for accident/medical emergency Out of Network: 80% of approved amount after deductible, 100% of approved amount for initial exam for accident/medical emergency In Network: 100% of approved amount Out of Network: 80% of approved amount after deductible In Network: 100% of approved amount Hospital Care Out of Network: 80% of approved Prescriptions Physician Office Visit Vision Deductible Maximum Out of Pocket amount after deductible In Network: Co-pay $5 generic/$10 brand Out of Network: 75% of approved amount In Network: $5 co-pay; 100% approved amount for initial exam for injury/ medical emergency Out of Network: 80% of approved amount after deductible; 100% approved amount for initial exam for injury/ medical emergency In Network: $10 co-pay for one exam per calendar year Out of Network: 80% of approved amount after deductible In Network: None Out of Network: $250 individual per calendar year In Network: None Out of Network: 100% after payments reach $2,500 SUPER HEALTH 90% of approved amount after deductible; 100% of approved amount for accidental injury 90% of approved amount after deductible 100% of approved amount 100% of approved amount plus $5 per day for private room Co-pay $5 generic/brand 90% of approved amount after deductible; 100% for accidental injury 90% of approved amount after deductible $250 per calendar year 100% after payments reach $1,000 DIRECTIONS Use the Health Plan Comparison Sheet to calculate the total out-of-pocket medical expense for each insurance plan, Health Choice and Super Health, and record your answers in the chart. When you begin, your deductible has not been met. The fee listed next to each item is the cost of that service without any health insurance. SERVICE AND COST COST WITH HEALTH CHOICE COST WITH SUPER HEALTH 1. Doctor's office visit for a sore throat and cough (in network) $95 2. Emergency room for stitches (in network) $115 DEDUCTIBLE NOW MET 3. Appendectomy (in network) » Surgery $14,000 » Two-night hospital stay $2,000 » Prescription (brand) $185 4. Eye exam (in network) $45 5. Urgent care (out of network) $85 6. Prescription (generic, in network) $85 7. Prescription (brand, out of network) $225 8. Annual physical (in network) $95 9. Emergency room for snowboard accident (concussion, broken leg, X-rays, etc.) $6,500 10. Urgent care (in network) $105