Insurance Carrier Co-pay Information Form
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Please complete for each health (medical, dental, vision, or prescription) plan (see the sample on page 2). If you would prefer, you can simply complete the top section of the form and attach the benefit summary for each health plan.
Company Name: ___________________________________ Phone: ____ ____ ____ Contact: ________________________ Email______________________________________________________ Type of Plan
Carrier
Health Plans
Dental Plans
Vision Plans
Co-Pay Amounts
Individual Insurance co-pays for
covered services
In-Network
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Out-ofNetwork
Sample Insurance Carrier Co-Pay Form
Type of Plan
Carrier
Health Plans
ABC Health Insurance Company
ABC Health Insurance Company ABC Health Insurance Company ABC Health Insurance Company ABC Health Insurance Company ABC Health Insurance Company ABC Health Insurance Company ZZZ Healthcare Co.
ZZZ Healthcare Co. ZZZ Healthcare Co. ZZZ Healthcare Co. ZZZ Healthcare Co. ZZZ Healthcare Co. ZZZ Healthcare Co. Dental Plans
XYZ Dental Insurance Company
XYZ Dental Insurance Company XYZ Dental Insurance Company XYZ Dental Insurance Company Vision Plans
123 Vision Insurance Company
123 Vision Insurance Company 123 Vision Insurance Company Co-Pay Amounts
Individual Insurance co-pays for
covered services
In- Network
Out-ofNetwork
Prescription – Generic
Prescription – Formulary
Prescription – non-formulary
Office Visit Co-pay
Preventative Care
In-patient hospital
Emergency Care
Prescription – Generic
Prescription – Formulary
Prescription – non-formulary
Office Visit Co-pay
Preventative Care
In-patient hospital
Emergency Care
$20
$30
$40
$25
$0
$100
$150
$10
$20
$30
$20
$0
$100
$150
$40
$60
$60
$50
$100
$300
$300
$20
$40
$60
$50
$100
$300
$300
Routine Exams
Fillings
Crowns/Bridges
$25
$50
$100
$50
n/a
n/a
Routine Exam
Eyeglasses
Contact Lenses
$25
$100
$100
$50
n/a
n/a