Plan Comparison Sample

Meet Jack & Diane They are empty nesters, with their kids all aged off of their medical plan. They're active and reasonably healthy with just a few medical services needed each year. Annual medical services: ACTUAL COST In their plan year, both Jack GOLD PLAN SILVER PLAN and Diane get their annual physical. There is no cost to the Jack & Diane Pay Jack & Diane Pay member for preventive services. Annual physical x6 $0 $0 $0 Jack sees a cardiologist twice a Cardiologist office visit x2 $460 ($230/visit) $35 copay x2 $105 copay x2 year and takes a regular Tier 2 medication Heart medication x12 $420 in copays/year $35 copay x12 $35 copay x12 Jack receives an Echocardiogram test $2,800 $500 ded; $100 copay $750 ded; $205 coinsurance echocardiogram test Orthopedic office visit $230 $35 copay $105 copay Diane sees an orthopedic specialist for a knee injury and Pain medication x4 $80 in copays/year $20 copay x4 $20 copay x4 is prescribed a Tier 1 medication to manage the pain Orthopedic surgery $3,500 $250 ded; $500 copay $375 ded; $312 coinsurance PCP office visit $150 $25 copay $30 copay Diane later elects to have outpatient knee surgery Overall cost of services Overall cost of services Deductible $750 $1,125 Diane visits her PCP for an office visit Coinsurance $0 $517 Copays $1,230 $635 Annual Payroll Deductions $6,180 $4,860 If you have no medical claims / year / year $8,160 $7,137 all year, you will save $1,320 in payroll deductions by *ABC's family deductibles are embedded, meaning no single individual on a family plan Save $1,023 on this plan will have to pay a deductible higher than the individual deductible amount. The two- selecting the silver plan person amount for the gold plan is $750, and the silver plan is $1,125.

Meet Carlos! Carlos works hard and plays hard. He's very active and healthy, with the occasional sports injury. The below is a sample snapshot comparison of the out-of-pocket medical costs he will incur based on the ABC plan he selects and his own unique healthcare needs. Your medical costs may vary. Annual medical services: ACTUAL COST GOLD PLAN SILVER PLAN He gets his annual physical. Carlos Pays Carlos Pays There is no cost to the Annual Physical $0 $0 $0 member for this preventive service. He is prescribed allergy Allergy Medication x4 $80 ($20/fill) $20 copay x4 $20 copay x4 medication, a Tier 1 prescription, twice a year for seasonal allergies. Carlos will Emergency Room Visit $1,900 $500 deductible; $250 copay $750 deductible; $250 copay pay the copay for each of these prescriptions. He has a minor accident and Overall cost of services Overall cost of services visits the emergency room Deductible $500 $750 for treatment. He is responsible for paying the Coinsurance $0 $0 cost up to his deductible, Copays $290 $290 plus a copay. Annual Payroll Deductions $2,940 $2,340 If you have no medical claims all / year / year $3,730 $3,380 year, you will save $600 in payroll deductible by selecting the Silver Save $350 on this plan plan over the Gold plan

Calculate Your Potential Costs While we can't always predict medical needs, you can use this worksheet to help you calculate the potential out-of-pocket costs you could incur during the plan year to help you choose the best plan for you and your family. YOU YOUR SPOUSE YOUR DEPENDENT(S) Primary Care Physician (PCP) office visit $____________________ $____________________ $____________________ Specialist office visit $____________________ $____________________ $____________________ Imaging (MRI, CT & PET Scan) $____________________ $____________________ $____________________ Outpatient Surgery $____________________ $____________________ $____________________ Prescription Drugs $____________________ $____________________ $____________________ Other Expenses $____________________ $____________________ $____________________ Total Estimated Expenses $__________________ $__________________ $__________________ The average cost of The average cost of an The national average The average sticker Average Costs: bloodwork without MRI can range anywhere cost for a colonoscopy price of giving birth in insurance is $432, but from $400 to $12,000, at inpatient facilities is Massachusetts hospitals the price can range from depending on the place $4,350, while the same is $14,063. $50 to upwards of of service. procedure at outpatient $1,000 depending on facilities averaged what tests are $2,550. performed.