Welcome to the HSHS Healthy Plan Cost Estimator tool. The purpose of this tool is to assist you in choosing a medical plan and understanding the advantages of tax-free accounts by helping you estimate your annual out-of-pocket medical expenses.

We respect your privacy. None of the information you use to calculate your out-of-pocket costs can be collected or tracked, including your expected annual medical care expenses. When you navigate away from the HSHS Healthy Plan Cost Estimator tool, your information is automatically discarded. You can print your selections and criteria from the HSHS Healthy Plan Cost Estimator tool. Please keep your printouts secure and use caution when printing to shared printers.

By using this tool, you are automatically agreeing that you understand and accept the following:

Estimates are based on national average medical costs. Because costs can vary by provider and not all service details are included, actual costs may differ from what is shown in the HSHS Healthy Plan Cost Estimator. Actual costs may also vary based on the order in which services are incurred and by the specific family member using a service (if applicable). In the event of any contradiction between the information contained in this tool and the Plan Documents, the Plan Documents shall govern in all cases.

This tool is designed to help you choose the medical plan that is right for you in two easy steps:

• The first is to tell us about you by selecting your level of coverage.
• The second is to tell us about your and your family's expected health care needs for the coming year by selecting whether you expect medical needs to be low, medium, or high for each family member.

Then, you'll be able to see an estimate of what you'll spend annually for the upcoming year under each medical plan option. You can also use the Health Savings Account section to consider how much you should contribute on a pre-tax basis to cover your expected medical expenses.

Optimal Viewing

This tool is designed for optimal performance in Internet Explorer 9 and later, and recent versions of Mozilla Firefox and Google Chrome. If you are using an earlier version or a web browser not listed, you may experience errors or be unable to use the tool correctly. In this case, please access the tool again using one of the listed web browser versions.

For optimal viewing, set the screen resolution to 1024 x 768 or higher.

The following cost assumptions were used in the tool:

Preventive Care
Adult routine physical	$134
Annual well woman exam (GYN)	$154
Well child/well baby exam	$120
Mammogram	$169
Pap test	$37
PSA test	$24
Colonoscopy	$2,775
Outpatient Care
HSHS Preferred PCP office visit	$94
Emergency room visit - facility charge	$1,503
Emergency room visit - physician charge	$178
Allergy shots	$16
Allergy serum	$527
Physical/occupational/speech therapy	$123
Lab and Diagnostic Testing
Complete CBC	$14
X-ray (chest)	$67
CT scan	$1,368
MRI (lumbar spine)	$1,538
Maternity Care
Childbirth: Normal delivery - facility charge	$5,390
Childbirth: Normal delivery - physician charge	$3,842
Childbirth: Cesarean section delivery - facility charge	$7,453
Childbirth: Cesarean section delivery - physician charge	$5,181
Prescriptions: Retail Pharmacy (30 day supply)
Acid reflux	$55
Asthma	$127
Cholesterol	$60
Depression	$27
Diabetes	$311
High Blood Pressure	$22
Prescriptions: Home Delivery (90 day supply)
Acid reflux	$132
Asthma	$313
Cholesterol	$164
Depression	$79
Diabetes	$763
High Blood Pressure	$59

Preventive Care
Adult routine physical	$185
Annual well woman exam (GYN)	$209
Well child/well baby exam	$164
Mammogram	$172
Pap test	$74
PSA test	$58
Colonoscopy	$3,892
Outpatient Care
HSHS Preferred PCP office visit	$138
Emergency room visit - facility charge	$2,184
Emergency room visit - physician charge	$299
Allergy shots	$29
Allergy serum	$527
Physical/occupational/speech therapy	$185
Lab and Diagnostic Testing
Complete CBC	$33
X-ray (chest)	$151
CT scan	$1,615
MRI (lumbar spine)	$2,364
Maternity Care
Childbirth: Normal delivery - facility charge	$7,168
Childbirth: Normal delivery - physician charge	$5,447
Childbirth: Cesarean section delivery - facility charge	$13,599
Childbirth: Cesarean section delivery - physician charge	$6,774
Prescriptions: Retail Pharmacy (30 day supply)
Acid reflux	$55
Asthma	$127
Cholesterol	$60
Depression	$27
Diabetes	$311
High Blood Pressure	$22
Prescriptions: Home Delivery (90 day supply)
Acid reflux	$132
Asthma	$313
Cholesterol	$164
Depression	$79
Diabetes	$763
High Blood Pressure	$59

Preventive Care
Adult routine physical	$180
Annual well woman exam (GYN)	$180
Well child/well baby exam	$152
Mammogram	$180
Pap test	$59
PSA test	$34
Colonoscopy	$3,351
Outpatient Care
HSHS Preferred PCP office visit	$116
Emergency room visit - facility charge	$2,270
Emergency room visit - physician charge	$214
Allergy shots	$26
Allergy serum	$602
Physical/occupational/speech therapy	$116
Lab and Diagnostic Testing
Complete CBC	$13
X-ray (chest)	$80
CT scan	$1,465
MRI (lumbar spine)	$1,929
Maternity Care
Childbirth: Normal delivery - facility charge	$6,134
Childbirth: Normal delivery - physician charge	$4,985
Childbirth: Cesarean section delivery - facility charge	$11,371
Childbirth: Cesarean section delivery - physician charge	$5,774
Prescriptions: Retail Pharmacy (30 day supply)
Acid reflux	$55
Asthma	$127
Cholesterol	$60
Depression	$27
Diabetes	$311
High Blood Pressure	$22
Prescriptions: Home Delivery (90 day supply)
Acid reflux	$132
Asthma	$313
Cholesterol	$164
Depression	$79
Diabetes	$763
High Blood Pressure	$59

Preventive Care
Adult routine physical	$234
Annual well woman exam (GYN)	$234
Well child/well baby exam	$168
Mammogram	$158
Pap test	$81
PSA test	$37
Colonoscopy	$3,328
Outpatient Care
HSHS Preferred PCP office visit	$128
Emergency room visit - facility charge	2,282
Emergency room visit - physician charge	$324
Allergy shots	$41
Allergy serum	$441
Physical/occupational/speech therapy	$99
Lab and Diagnostic Testing
Complete CBC	$26
X-ray (chest)	$94
CT scan	$1,779
MRI (lumbar spine)	$2,572
Maternity Care
Childbirth: Normal delivery - facility charge	$6,197
Childbirth: Normal delivery - physician charge	$4,732
Childbirth: Cesarean section delivery - facility charge	$10,021
Childbirth: Cesarean section delivery - physician charge	$5,545
Prescriptions: Retail Pharmacy (30 day supply)
Acid reflux	$55
Asthma	$127
Cholesterol	$60
Depression	$27
Diabetes	$311
High Blood Pressure	$22
Prescriptions: Home Delivery (90 day supply)
Acid reflux	$132
Asthma	$313
Cholesterol	$164
Depression	$79
Diabetes	$763
High Blood Pressure	$59

Please select the group that applies to you.

Indicate whether you would like to include coverage for yourself, or for yourself and a spouse or domestic partner.

If you have more than five children, consider combining expenses for children to estimate your total family costs.

Please select the region that best represents where you live. While costs vary somewhat from region to region, the differences are generally not significant and may not affect your overall results.

Please indicate your salary band. Annual employee premiums will very based on your selection.

To qualify for Favorable Deductions, both of the following must be true for you:

• I have taken a well-being assessment by the deadline, and
• I have taken a health screening by the deadline.

A premium surcharge applies if any of the individuals use tobacco.

Low health care usage means that you and your family typically only use your medical coverage for preventive care (i.e., some lab tests and preventive prescription drugs) and one or two doctor visits a year.

• 1 routine physical
• 2 HSHS preferred PCP office visits
• 1 complete CBC
• 2 prescriptions: retail - acid reflux

Medium health care usage means that you and your family see the doctor a few times a year for an illness, an injury or a chronic condition and incur prescription drug costs.

• 1 routine physical
• 3 HSHS preferred PCP office visits
• 3 complete CBC
• 1 X-ray (chest)
• 1 emergency room - facility visit
• 1 emergency room - physician visit
• 2 prescriptions: retail - acid reflux
• 2 prescriptions: retail - cholesterol
• 2 prescriptions: retail - high blood pressure

High health care usage means that you and your family use your medical coverage to manage a complex condition, injury or procedure that requires a number of doctors' visits, prescription drugs on a regular basis and perhaps an inpatient hospital stay, including a birth (regular or Caesarean delivery).

• 1 routine physical
• 6 HSHS preferred PCP office visits
• 10 complete CBC
• 1 X-ray (chest)
• 1 emergency room - facility visit
• 1 emergency room - physician visit
• 1 MRI scan
• 1 childbirth: normal delivery - facility
• 1 childbirth: normal delivery - physician
• 8 prescriptions: retail - acid reflux
• 4 prescriptions: retail - cholesterol
• 4 prescriptions: retail - high blood pressure

[Information about the HSA and FSA accounts would go here.]