Plan Inputs
Enter deductible and out-of-pocket settings, then add claim lines for family members.
Example Data Table
Sample claim entries you can replicate using the “Fill example” button.
| Member | Allowed amount | Copay | Deductible-exempt | Scenario note |
|---|---|---|---|---|
| Member 1 | $1,250 | $40 | No | Specialist visit with lab work |
| Member 2 | $900 | $25 | No | Imaging service |
| Member 3 | $300 | $0 | Yes | Preventive care example |
| Member 1 | $2,600 | $0 | No | Outpatient procedure |
Formula Used
- Billable amount = Allowed − Copay (when copay reduces billable), otherwise Allowed.
- Deductible applied = min(Billable, remaining deductible limits).
- Coinsurance = (Billable − Deductible applied) × Coinsurance% (after deductible is satisfied).
- Line out-of-pocket = Copay + Deductible applied + Coinsurance.
- OOP caps: Patient pay is limited by individual and family out-of-pocket maximums.
- Plan paid ≈ Allowed − Patient paid (after caps).
How to Use This Calculator
- Enter your plan’s deductibles, coinsurance, and out-of-pocket maximums.
- Select the deductible design: embedded or aggregate.
- Add claim lines with an allowed amount, plus any copay.
- Mark deductible-exempt services when they don’t apply to deductible.
- Click Calculate to see results above the form.
- Use CSV or PDF export to save and share scenarios.
Assumptions & Notes
This tool is designed for planning and comparison. It does not replace insurer benefit documents. Coverage categories, network rules, Rx tiers,
and service-specific copay rules may differ from these simplified assumptions.