| Health Plan Checklist | |||
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Monthly Premium | ||
| Individual or family, as appropriate |  |
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Deductible (individual or family) | ||
| In network | |
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| Out of network | |
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| Separate hospital deductible | |
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Co-Payment Rate | ||
| In network | |
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| Out of network | |
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Special Co-Payments | ||
| M.D. office visit | |
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| Emergency-room visit | |
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| Mental-health treatment | |
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| Brand-name drugs | |
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| Generics | |
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| Other | |
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Annual Limits | ||
| Days in hospital | |
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| Spending per beneficiary | |
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| Number of visits or service | |
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Maximum out of Pocket | ||
| Maximum out of pocket | |
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Lifetime Limit | ||
| Lifetime Limit | |
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