WORKSHEET FOR COMPARING

THE BENEFIT OPTIONS FOR

DOUGLAS COUNTY

Calculations

Column A

Prime High

Column B

CDHP/HRA

All enrolled family members should be considered in the below calculations.

Amounts used for Column B are average costs, use the actual cost if known.

STEP ONE

1.  Total number of Preventive Care Office Visits per family per year:

Both Column A and B = Multiply number of visits by $15

2.  Total # Non-Preventive Office Visits in a year:

Column A = Multiply the number of office visits by $15;

Column B =  Multiply the number of visits by $87 (average cost)

3.  Total # Hospital Stays for all family members:

For each expected day in the hospital:

Column A = multiply by $100

Column B = multiply by $2,800

4.  Total # Urgent Care Visits in a year:

For each visit :

Column A = multiply by $15

Column B = multiply by $80

5.  Total # Emergency Room visits in a year:

For each visit :

Column A = multiply by $50

Column B = multiply by $840

6.  Total # rehabilitation or physical therapy visits in a year:

For each visit :

Column A = multiply by $15

Column B = multiply by $60

7.  Total Cost of X-ray and Lab services:

Estimate the total dollar amount of services and

Column A = Enter $0

Column B = Enter entire dollar amount

8.  Total # of Home Health Care Visits in a year:

For each visit :

Column A = multiply by $15

Column B = multiply by $50

9.  Total charges for Other Services subject to 20% coinsurance:

Estimate the total dollar amount of services and

Column A = multiply by 20%;

Column B = Enter entire dollar amount

10.  Total Actual cost (100%) of all prescription drugs (before reimbursement):

Column B only = Calculate the total cost of all Rx for the entire year

N/A

11.  Sub Total Costs subject to Deductible and Out of Pocket limit:

Add lines 1 through 12:

12.  Deductible:

Column A = Enter $0;

Column B =  Enter either $1,500 for single or $3,000 for family column

Column A = Enter $0;

Column B =  Enter the lesser of Line 13 or line 14

Column A =  Amount in

Step One Line 13;

Column B = Amount in

Step One Line 13 minus

Step Two line 1; If $0

or less, enter $0, if > $0 Multiply result by 20%

3.  Maximum Out of Pocket Limit to be applied

after deductible:

Column A =  $1,000

multiplied by each

family member;

Column B = $1,500

multiplied by up to

2 family members

Both Column A and

Column B =  the lesser

of  the amount in Step

Two Line 2 or

Step Two Line 3

5.  Total # of Generic Rx purchased in one

year ($10 each):

Column A only = Multiply

the number of generic Rx

filled by $10

6.  Total # of Brand Name Rx purchased in a

year ($20 each):

Column A only = Multiply

the number of brand Rx

filled by $20

7.  Total # Non Formulary Brand Rx purchased

in a year ($30 each)

Column A only = Multiply

the number of brand Rx

filled by $30

N/A

Column A = Step Two

Lines 4 + 5 + 6 + 7

Column B  = Step Two

Lines 1 + 4

Amount of Health Reimbursement Arrangement (HRA):

Column B only = Enter

$900 for single and $1,800 for family

Column A = Step Two Line 7

Column B = Step Two Line 7

minus Step Three

Potential Roll Over Amount in HRA for Next Year:

If the result of Step Four in

Column B is negative, this

is the HRA amount you

could carry over into the

next plan year

Column A = Amount of Prime High premiumshare before dental premium X 12 months ($61.98 x 12) Column B = Amount of CDHP/HRA premium share before dental X 12 months ($0 x 12 )

Both Column A and Column

B =  The total of Step Four

and Step Six