Cheyenne Regional Medical Center Plan Selection Work Sheet
Note: Choosing a health insurance plan is both a financial decision AND a health decision. Prior to selecting a plan consider your health needs and your financial capability. This tool is designed to help you consider your health plan options and make the best decision for you and/or your family.
Tip: If you utilize health care beyond annual well visits and check-ins (more than an average of two to three times per year) due to chronic disease management or other health needs, consider a plan with less out-of-pocket costs at time of care (ex. copays, coinsurance, deductible, etc.) This tool will help you assess your total estimated cost of care, including your premium, for a year.
Before Selecting a Plan, consider the following:
1)How often do you visit your Primary Care Provider (Doctor, Nurse Practitioner, Physician Assistant)?
___ Once per year for my well visit
___ 2 times per year (ex. well visit, cold and flu)
___ 4 or more times per year (ex. well visit, chronic disease management, immunodeficiency, etc.)
2)How often do you visit a specialist (ex. cardiologist, neurologist, oncologist, mental health provider, etc.)?
___Never
___1-2 or more times per year
___3 or more times per year
3)How often do you need lab work?
____Never
____ Only as a participant in the CRMC Wellness Program (Note: This is not charged to your health plan.)
____ Annually (not a part of Wellness Blood Draw)
____ Biannually
____ Quarterly
____ Monthly
4)Do you need other health care such as physical therapy or other therapy?
_____ Yes _____ No
5)Are you taking prescription medication daily? _____ Yes ______No
Tip: If you take prescription medication, consider the tier of medication (generic, preferred brand, non-preferred brand, specialty) and the associated cost to you when selecting a health insurance plan. You may review the provider network and check the tier of your medication by logging into your UMR account at
Before Selecting a Plan, compare the plans. Consider the health needs as indicated above and calculate the costs.
Individual Only
Preferred Provider Organization (PPO) Details / Medical Basic Plan / Medical Plus PlanMonthly Premium/Cost Per Check
Deductible (medical)
Out-of-Pocket Max
Copays/Coinsurance / Amount / Amount
Primary Care Provider (PCP) Visit
Specialist Visit
Emergency Room (ER) Visit
Inpatient Hospital Stay
Other Service: ______
Other Service: ______
Prescriptions: Use your prescription list and UMR’s medication list/covered drugs
Generic Drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Healthcare Providers / In Network/Covered? / In Network/Covered?
Current provider:
Other provider or hospital:
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Additional Resources:
1)Review the provider network and check the tier of your medication by logging into your UMR account at
2)For questions about plan details, you may contact Benefits at .
Before Selecting a Plan, compare the plans. Consider the health needs as indicated above and calculate the costs.
Individual Plus Family
Preferred Provider Organization (PPO) Details / Medical Basic Plan / Medical Plus PlanMonthly Premium/Cost Per Check
Deductible (medical)
Out-of-Pocket Max
Copays/Coinsurance / Amount / Amount
Primary Care Provider (PCP) Visit
Specialist Visit
Emergency Room (ER) Visit
Inpatient Hospital Stay
Other Service: ______
Other Service: ______
Prescriptions: Use your prescription list and UMR’s medication list/covered drugs
Generic Drugs
Preferred brand name drugs
Non-preferred brand name drugs
Specialty drugs
Healthcare Providers / In Network/Covered? / In Network/Covered?
Current provider:
Other provider or hospital:
Other Considerations
Other Consideration:
Other Consideration:
Other Consideration:
Additional Resources:
1)Review the provider network and check the tier of your medication by logging into your UMR account at
2)For questions about plan details, you may contact Benefits at .