Emergency room $ $ $ Urgent care center $ $ $ Maternity Care Pre-natal and post-natal care $ $ $ Hospital services (mother and child) $ $ $ How many post delivery recovery days available Substance Abuse Co-Pay Inpatient ___ visits allowed per calendar year $ $ $ Outpatient ___ visits allowed per calendar year $ $ $ (The Mental Health Parity and Addiction Equity Act prohibits plans from imposing Mental Health Co-Pay higher deductibles or co-pays or tighter limits on visits than are allowed for medical services in the plan) $ $ $ Inpatient _ visits allowed per calendar year $ $ $ Outpatient visits allowed per calendar year Yes Yes Yes □ □ □ Pharmacy Benefits Co-Pay (do you have a copy of the plan's drug formulary list?) No No No □ □ □ $ $ $ Yearly deductible Individual $ $ $ Yearly deductible Family Co-pay Tier 1 (generics) $ $ $ $ $ $ Co-pay Tier 2 (Formulary/brand) $ $ $ Co-pay Tier 3 (Non-Formulary) Co-insurance Tier 4 (Specialty Tier) - % cost share or co- $ or % $ or % $ or % pay Yes Yes Yes □ □ □ If your plan has a specialty tier with co-insurance is there No No No a maximum per prescription? □ □ □ Yes Yes Yes □ □ □ Is there an annual pharmacy maximum out-of-pocket? No No No □ □ □ Yes Yes Yes □ □ □ Is immunoglobulin therapy covered under the No No No pharmacy benefit? □ □ □ Yes Yes Yes □ □ □ Do you have more than one choice of ‘specialty’ No No No pharmacy provider? □ □ □ Yes Yes Yes □ □ □ Is there a preferred specialty pharmacy? No No No □ □ □ (Worksheet continued on next page) (ongoing co-pays after deductible is met) Other (if offered) $ $ $ Chiropractic visits allowed per calendar year
Emergency room $ $ $ Urgent care center $ $ $ Maternity Care Pre-natal and post-natal care $ $ $ Hospital services (mother and child) $ $ $ How many post delivery recovery days available Substance Abuse Co-Pay Inpatient ___ visits allowed per calendar year $ $ $ Outpatient ___ visits allowed per calendar year $ $ $ Mental Health Co-Pay (The Mental Health Parity and Addiction Equity Act prohibits plans from imposing higher deductibles or co-pays or tighter limits on visits than are allowed for medical services in the plan) Inpatient _ visits allowed per calendar year $ $ $ Outpatient visits allowed per calendar year $ $ $ Pharmacy Benefits Co-Pay (do you have a copy of the plan's drug formulary list?) Yes □ No □ Yes □ No □ Yes □ No □ Yearly deductible Individual Yearly deductible Family $ $ $ $ $ $ Co-pay Tier 1 (generics) $ $ $ Co-pay Tier 2 (Formulary/brand) $ $ $ Co-pay Tier 3 (Non-Formulary) $ $ $ Co-insurance Tier 4 (Specialty Tier) - % cost share or co- pay $ or % $ or % $ or % If your plan has a specialty tier with co-insurance is there a maximum per prescription? Yes □ No □ Yes □ No □ Yes □ No □ Is there an annual pharmacy maximum out-of-pocket? Yes □ No □ Yes □ No □ Yes □ No □ Is immunoglobulin therapy covered under the pharmacy benefit? Yes □ No □ Yes □ No □ Yes □ No □ Do you have more than one choice of ‘specialty’ pharmacy provider? Yes □ No □ Yes □ No □ Yes □ No □ Is there a preferred specialty pharmacy? Yes □ No □ Yes □ No □ Yes □ No □ (Worksheet continued on next page) Other (if offered) (ongoing co-pays after deductible is met) Chiropractic visits allowed per calendar year $ $ $
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