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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