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Managed Care
Comparison Worksheet
Gail Carlson, MPH Ph.D, State Health Education Specialist, University of Missouri Extension
| Plan Name | #1 | #2 | #3 |
| Premium Amount | $ | $ | $ |
| Deductible (per year) | $ | $ | $ |
| Co-payment Required Hospital/Physician Prescription Drugs Ambulance Medical Supplies Other______________ |
$________ $________ $________ $________ $________ |
$________ $________ $________ $________ $________ |
$________ $________ $________ $________ $________ |
| Out of Pocket Maximum | $ | $ | $ |
| Maximum Lifetime Benefits | $ | $ | $ |
| Are physicians who you currently
use signed up with the plan? Primary Care Provider Internal Medicine Gynecology Other______________ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
| Is emergency care covered? | Yes___ No___ | Yes___ No___ | Yes___ No___ |
| Are there any limitations/ restrictions in hospitalization coverage? If yes, what are they? |
Yes___ No___
|
Yes___ No___
|
Yes___ No___
|
| Is the doctor you are considering as your primary care physician comfortable with the plan? |
Yes___ No___ | Yes___ No___ | Yes___ No___ |
| If you require the services of a specific specialist who is not part of the plan, will the plan refer you to that physician? What will it cost? |
Yes___ No___ $ |
Yes___ No___ $ |
Yes___ No___ $ |
| Are any of the following services covered? Dental Care Vision Care Mental Health Chemical Dependency Preventive Health Screenings Other__________________ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ Yes___ No___ |
| Are there clear directions on how to use the grievance procedure? | Yes___ No___ |
Yes___ No___ |
Yes___ No___ |
| Are you covered if you become ill away from home, including if you travel abroad? |
Yes___ No___ |
Yes___ No___ |
Yes___ No___ |
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Last Updated 05/05/2009
