Copay and Premium Comparison Calculator

Enter plan details and expected usage

Use copay-based mode for quick estimates, or allowed-charge mode for a more detailed deductible simulation.

Plan A

Fill the fields you know. Unknowns can be left as zero.

Plan name

Monthly premium ($)

Annual deductible ($)

Coinsurance after deductible (%)

Out-of-pocket maximum ($)

Estimation mode

After-deductible rule (detailed mode)

Copays and allowed charges

In detailed mode, add average allowed charges to simulate deductible usage. If you leave allowed charges at zero, the calculator falls back to copays for that service.

Primary care copay ($)

Primary care visit

Avg allowed per primary visit ($)

Optional for detailed mode

Specialist copay ($)

Specialist visit

Avg allowed per specialist visit ($)

Optional for detailed mode

Urgent care copay ($)

Urgent care visit

Avg allowed per urgent care visit ($)

Optional for detailed mode

ER copay ($)

Emergency room visit

Avg allowed per ER visit ($)

Optional for detailed mode

Generic Rx copay ($)

Generic Rx fill (30-day)

Avg allowed per generic fill ($)

Optional for detailed mode

Brand Rx copay ($)

Brand Rx fill (30-day)

Avg allowed per brand fill ($)

Optional for detailed mode

Lab copay ($)

Lab test

Avg allowed per lab test ($)

Optional for detailed mode

Imaging copay ($)

Imaging

Avg allowed per imaging service ($)

Optional for detailed mode

Plan B

Compare a second plan using the same usage assumptions.

Plan name

Monthly premium ($)

Annual deductible ($)

Coinsurance after deductible (%)

Out-of-pocket maximum ($)

Estimation mode

After-deductible rule (detailed mode)

Copays and allowed charges

Use the same service list as Plan A to keep comparisons consistent.

Primary care copay ($)

Primary care visit

Avg allowed per primary visit ($)

Optional for detailed mode

Specialist copay ($)

Specialist visit

Avg allowed per specialist visit ($)

Optional for detailed mode

Urgent care copay ($)

Urgent care visit

Avg allowed per urgent care visit ($)

Optional for detailed mode

ER copay ($)

Emergency room visit

Avg allowed per ER visit ($)

Optional for detailed mode

Generic Rx copay ($)

Generic Rx fill (30-day)

Avg allowed per generic fill ($)

Optional for detailed mode

Brand Rx copay ($)

Brand Rx fill (30-day)

Avg allowed per brand fill ($)

Optional for detailed mode

Lab copay ($)

Lab test

Avg allowed per lab test ($)

Optional for detailed mode

Imaging copay ($)

Imaging

Avg allowed per imaging service ($)

Optional for detailed mode

Usage assumptions (annual)

These counts drive the estimated out-of-pocket totals.

Primary care visits

Preventive primary visits (covered $0)

Specialist visits

Urgent care visits

ER visits

Generic Rx fills (30-day)

Brand Rx fills (30-day)

Lab tests

Imaging services

Other allowed medical costs ($)

Example: therapy sessions, procedures, durable equipment, etc.

Tip: If you choose detailed mode, enter average allowed costs for common services. This helps the calculator estimate how quickly you reach the deductible.

Example data table

Sample scenarios below show how premiums and copays can trade off. Replace these with your plan’s numbers for accurate results.

Scenario	Usage highlights	Lower premium plan	Higher premium plan	Common outcome
Low utilization	1–2 visits, few prescriptions, no tests	Often lower total	May cost more overall	Premiums dominate the yearly total
Moderate utilization	3–5 visits, several fills, some labs	Can be competitive	Can be competitive	Copays and premium trade-offs matter
High utilization	Specialist care, imaging, larger allowed costs	May spike out-of-pocket	May protect out-of-pocket	Deductible, coinsurance, and OOP max drive totals

Formula used

Annual premium

Annual Premium = Monthly Premium × 12

Estimated annual total

Estimated Total = Annual Premium + Estimated Out-of-Pocket

Out-of-pocket estimation

Copay-based mode: Out-of-pocket ≈ Σ(copay × count) + deductible/coinsurance on “other allowed costs”.
Allowed-charge mode: Each service occurrence applies to remaining deductible first, then uses your selected after-deductible rule (copay, coinsurance, or both).
If an out-of-pocket maximum is provided, out-of-pocket is capped at that maximum.

Important: Real plan rules vary (network pricing, exemptions, embedded deductibles, tiered drugs). Use this calculator for planning, not final billing.

How to use this calculator

Enter monthly premiums, deductibles, coinsurance, and out-of-pocket maximums for both plans.
Fill in copays for common services (visits, prescriptions, labs, imaging).
Choose a mode:
- Copay-based for quick comparisons.
- Allowed-charge for a deductible-aware estimate. Add average allowed costs if you know them.
Set your expected yearly usage counts and optional “other allowed medical costs”.
Press Submit to see the result below the header and above the form.
Use Download CSV or Download PDF for sharing and budgeting.

Premium share of annual spending

For many households, premiums are the largest predictable cost. If a plan costs $320 per month, the annual premium is $3,840. A $240 monthly premium totals $2,880, a $960 gap before any care. The calculator shows how much care is needed to overcome that premium spread. It supports budgeting for expected care.

Copay sensitivity by visit volume

Copays scale linearly with usage. Ten primary visits at a $25 copay add $250, while a $35 copay adds $350. Two specialist visits at $45 add $90, versus $60 adding $120. Add four generic fills at $10 ($40) compared with $15 ($60). When routine services rise from 10 to 25 events, a $10 per‑event difference increases annual cost by $150.

Deductible crossover points

In detailed mode, allowed charges consume the deductible first. With a $1,500 deductible and $200 allowed per visit, about eight such services can exhaust it. A $3,000 deductible needs roughly fifteen. If labs average $75 and imaging averages $600, one imaging event equals eight lab tests toward meeting the deductible. Once met, post‑deductible rules shift costs toward coinsurance or fixed copays, changing which plan is cheaper.

Coinsurance impact on larger claims

Coinsurance matters most for imaging, ER, and lump‑sum “other allowed costs.” For a $2,000 allowed claim after the deductible, 20% coinsurance pays $400, while 30% pays $600. For $6,000 of allowed costs, that becomes $1,200 versus $1,800. If two such claims occur, the difference is $1,200, often larger than a year of premium savings. The chart makes these swings visible.

Role of the out-of-pocket maximum

The out‑of‑pocket maximum caps eligible spending. If projected out‑of‑pocket reaches $8,200 but the cap is $7,000, the model reduces costs by $1,200. A plan with a $7,500 cap would reduce the same scenario by $700. Lower caps can be valuable when a single hospital event triggers multiple services, because the limit stops further eligible cost sharing.

FAQs

1) What does the calculator compare?

It estimates each plan’s annual premium plus expected out-of-pocket spending from your usage, copays, deductible, coinsurance, and out-of-pocket maximum, then shows the lower-cost option.

2) When should I use allowed-charge (detailed) mode?

Use it when you know typical allowed charges or want deductible sequencing. It applies allowed costs to the remaining deductible first, then charges copay, coinsurance, or both based on your selected rule.

3) How is preventive care handled?

Preventive primary visits are treated as $0 and excluded from copay calculations. Set “Preventive primary visits” up to your total primary visits to model common preventive coverage rules.

4) Does the out-of-pocket maximum include premiums?

No. The out-of-pocket maximum caps eligible medical cost sharing in the estimate. Premiums are added separately because they are paid regardless of utilization.

5) Why do my results change a lot with coinsurance?

Coinsurance applies to larger allowed charges after the deductible is met. Imaging, ER, and “other allowed costs” can be sizable, so a 10-point difference can materially move the annual total.

6) Can I share results with someone else?

Yes. After you submit, use Download CSV for spreadsheets or Download PDF for a clean summary. The exported files reflect your latest inputs and the displayed comparison totals.

Enter plan details and expected usage

Example data table

Formula used

How to use this calculator

Premium share of annual spending

Copay sensitivity by visit volume

Deductible crossover points

Coinsurance impact on larger claims

Role of the out-of-pocket maximum

FAQs

1) What does the calculator compare?

2) When should I use allowed-charge (detailed) mode?

3) How is preventive care handled?

4) Does the out-of-pocket maximum include premiums?

5) Why do my results change a lot with coinsurance?

6) Can I share results with someone else?

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