Health Plan Comparison Form
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4Health insurance
Plan comparison form
If you’re shopping for health insurance, use this form to compare health insurance plans.
1.
Plan costs
Plan 1:
Plan 2:
$________ per Month
$________ per Month
Monthly premium amount
Hospital visits:
$________ per year
$________ per year
How much is the
annual deductible?
Medical care:
$________ per year
$________ per year
Prescriptions:
$________ per year
$________ per year
Total:
$____________
$____________
Office visits:
$________ per visit
$________ per visit
How much is
your copay or
Hospital visits:
$________ per stay
$________ per stay
coinsurance?
Prescriptions:
$________ per Rx fill
$________ per Rx fill
Total yearly estimated
$____________
$____________
costs:
Are prescriptions
Prescription drug
Yes
No
Yes
No
costs
covered?
Does the plan cover
my prescription?
(Find out by checking
Yes
No
Yes
No
online or by calling
the company)
My total yearly
$____________
$____________
estimated costs:
What is the yearly
limit on my out-
of-pocket costs?
$____________
$____________
(Does it include the
deductible?)
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