General Plan Information

Make selections below in order to create a scenario for calculating your out of pocket costs. Check the "Calculate Your Costs" box if you have no more entries to make. Click the update button when you're ready to continue. Click the Copay/Coinsurance or Deductible/Maximums tabs if you want to customize your benefit information.

Demographics
Age Group	oopedb20<11-1718-4445-6465-8485+	Sex	Male Female		State	oopedb20AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDCDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingstate =

Plan Information
Select a plan model Select One oopedb20PPO High BenefitPPO Low BenefitHMO High BenefitHMO Medium BenefitHMO Low BenefitHMO Tiered BenefitPoint of ServiceConsumer Driven Plan *Assumed Plan Co-payments, Coinsurance, Deductibles and Benefit Maximums are based on the Plan Model you select.  You can change these assumptions by clicking the applicable tabs above.		Plan Name

Service, Treatment or Surgery

Select One oopedb20Alcohol and drug rehabilitation/detoxificationAppendectomyArthroscopyBone marrow biopsyBone marrow transplantBroken ArmCancer chemotherapyCesarean sectionColonoscopy and biopsyCoronary artery bypass graftDebridement of wound, infection or burnExcision of semilunar cartilage of kneegall bladder removalHeart valve proceduresHip replacement, total and partialHysterectomyInguinal and femoral hernia repairInsertion, revision, replacement, removal of cardiac pacemaker or cardioverter/defibrillatorKidney transplantKnee RepairKnee ReplacementLobectomy or pneumonectomy(lung Cancer)MastectomyNormal deliveryPeripheral vascular bypassPsychological and psychiatric evaluation and therapyRespiratory intubation and mechanical ventilationSkin graftTonsillectomy and/or adenoidectomyTreatment Methods for Kidney Failure: Peritoneal DialysisTreatment, fracture or dislocation of hip and femurTURP(Elarged prostate reduction)Upper gastrointestinal endoscopy, biopsy

Or Enter A Total Cost ($):      *Instead of selecting a service, treatment or surgery above, you can simply enter  a total estimated dollar cost.

Description

Coverage Information

Is your hospital a   Participating Hospital

Yes No

Individual or Family Coverage

Family Individual

Calculate Your Costs	*If checked, the record will be updated and a report generated

The Out of Pocket Calculator is a tool for comparing relative differences between health plans for your out of pocket costs when hospitalized.  Please review our disclaimer regarding use of the Calculator

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