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Health Plan Selection Tool - FARM_ParticipantWeb Page 1 of 1

Utilization Questionnaire Logged On: MOHAMMED TAREQ


Monday, November
To help you pick the medical plan that best suits your health care and budget needs, complete the questions below. The qu
ask you to forecast the health care services you and your dependents expect to receive in the upcoming plan year 2011. Co
what your health care utilization was in the past year. Was it typical? What do you anticipate for next year?

After you've finished entering your utilization numbers, click Next >> to see the cost analysis.

Enter the number of services you expect for 2011 Unit Cost
How many times do you expect to visit a general M.D. (e.g. general practitioner, pediatrician, OB-GYN)? $108 1
Will this person have an annual physical this plan year? $135 Y
How many times do you expect to visit a specialist (e.g. allergist, dermatologist, orthopedic, ENT, etc.)? $151 1
Is this person pregnant and expect to give birth this plan year? $6,000 N
How many times do you expect to have blood work, x-rays, or general lab work at an outpatient facility? $209 1
How many times do you expect to use the Emergency Room? $600 0
Do you expect this person to have an inpatient hospitalization, inpatient surgery or other covered major
Varies $0.
medical expense not listed?
How many generic prescriptions do you expect to fill at a retail outlet? $40 0
How many brand name prescriptions do you expect to fill at a retail outlet? $60 0
How many generic prescriptions do you expect to fill by mail order (31 to 90 day supply)? $120 0
How many brand name prescriptions do you expect to fill by mail order (31 to 90 day supply)? $180 0

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https://secure.aliquant.net/farm/PlanSelQuestions.aspx 11/7/2010