Name (optional)

First Name

Last Name

Enrollment *

Employee Only Coverage

Employee & Spouse Coverage

Employee & Children Coverage

Family Coverage

I will not be enrolling, I have coverage elsewhere.

I will not be enrolling, I have NO coverage elsewhere.

When thinking about health insurance, of the following, which is your number one goal?

A low weekly payroll deduction.

The plan deductible amount.

The annual maximum out of pocket amount.

The plan that covers my prescriptions.

I am not sure.

Which Plan Structure do you prefer?

HMO (Health Maintenance Organization) referrals required from your Primary Care Physician (PCP), must see in network doctors. This is most cost effective type of plan.

POS (Point of Service) May require a referral from your PCP to see a specialist, but you can see out-of-network doctors. Premiums slightly higher than HMO.

PPO (Preferred Provider Organization) Referral from PCP is not required to see physician or specialist of your choice. This plan has the highest premiums.

What is your desired yearly Deductible?

This is the amount insured members must pay out of pocket for certain services before cost sharing by insurance begins.

Deductible less than $3,000

Deductible between $3,500 and $5,000

Deductible between $5,500 and $8,000

Deductible greater than $8,500

I am not sure.

What is your desired yearly Maximum Out of Pocket cost?

This is the annual limit on your out-of pocket costs for your plan. This includes deductible and co-insurance amounts.

$3,000 for individual/$6,000 for family

$5,000 for individual/$10,000 for family

$7,000 for individual/$14,000 for family

$9,450 for individual/$18,200 for family

I am not sure.

Health Savings Accounts (HSA)

Plans that are HSA eligible are typically available for plans with deductibles of at least $3,500.

I want an HSA eligible option.

Having an HSA eligible option is not important to me.

If you needed a major medical procedure, would you be willing to travel away from home, but in New England, in order to save out-of-pocket cost to you?

Yes

Maybe

No

If your prescription is available via mail order for less money than your local pharmacy, would you be willing to receive your medication through the mail?

Absolutley

Maybe

No

NA

Did you have to obtain Prior Authorization for any of your current medications?

Yes

No

NA

Check all items you would like to see covered or partially covered by your health insurance plan:

Physical Therapy

Chiropractic Care

Acupuncture

Naturopathic/Functional Medicine Doctor

1 or 2 Sick Visits to your PCP each year

Type other suggestions in box below.