Inputs
Enter your expected yearly usage and each plan’s cost-sharing design. For coinsurance-based services, use total allowed charges you expect for labs, imaging, procedures, and hospital care.
How to Use This Calculator
- Estimate yearly visits, prescriptions, and expected coinsurance‑eligible allowed charges.
- Enter each plan’s premium, deductible, coinsurance rate, and out‑of‑pocket maximum.
- Add copays for visits and prescriptions for each plan.
- Click “Compare Plans” to see totals and the lowest estimate.
- Download a CSV for spreadsheets or a PDF for sharing.
Formula Used
Copays are summed from visit and prescription counts.
Deductible paid is applied to in‑network allowed charges first:
Coinsurance is charged on the remaining allowed charges:
Out‑of‑pocket before cap includes deductible, coinsurance, and optionally copays:
OOP after cap respects the plan maximum:
Net annual cost adds premiums and subtracts employer credit:
Example Data Table
Use these sample values to understand the inputs. Click “Load Example Values” above to populate the form quickly.
| Category | Example Value | Notes |
|---|---|---|
| PCP visits | 3 | Routine and follow‑ups |
| Specialist visits | 2 | Dermatology or cardiology |
| Urgent care visits | 1 | Minor illness or injury |
| Generic fills | 12 | Monthly maintenance medication |
| Preferred brand fills | 2 | Occasional branded medication |
| In‑network allowed charges | $3,500 | Labs, imaging, procedures, hospital care |
| Plan A premium | $240/month | Lower premium, higher deductible |
| Plan B premium | $310/month | Higher premium, lower OOP cap |
| Plan C premium | $185/month | Lowest premium, higher coinsurance |
Premium Load Versus Deductible Exposure
A plan with a $240 monthly premium costs $2,880 per year before care. A $310 premium plan costs $3,720, a difference of $840 that must be recovered through lower cost sharing. If the deductible is $1,500, early spending is mostly yours until allowed charges exceed that threshold. A higher premium plan can still win when it reduces later coinsurance and caps exposure sooner.
Expected Allowed Charges Drive Break-Even
Coinsurance-eligible allowed charges represent labs, imaging, procedures, and hospital services. With $3,500 of allowed charges, a $900 deductible plan reaches coinsurance sooner, but pays less deductible than a $1,500 deductible plan. After the deductible, 15% coinsurance on $2,600 equals $390, while 20% on $2,000 equals $400.
Copays Change the Speed of Reaching the Deductible
Visits and prescriptions create predictable copay totals. For example, 3 PCP visits at $25, 2 specialist visits at $50, and 12 generic fills at $15 produce $355 in copays. If a plan applies copays to the deductible, deductible remaining falls faster, shifting more spending into coinsurance. If copays also count toward the out-of-pocket maximum, they accelerate reaching the cap.
Out-of-Pocket Maximum Protects Catastrophic Years
The out-of-pocket maximum is the hard stop for covered in-network cost sharing. When modeled OOP before cap exceeds $6,000, the calculator limits it to $6,000, preventing runaway exposure. Comparing a $4,500 cap to a $7,500 cap matters most when allowed charges are high, such as a surgery year. If you include out-of-network allowed charges, the tool models a separate bucket with its own deductible and cap.
Using Credits and Sensitivity Checks
Employer or HSA credits reduce net annual cost dollar-for-dollar. A $600 credit can offset higher deductibles or coinsurance. Run the calculator twice: one scenario with routine care and another with elevated allowed charges, like $10,000. If the lowest-cost plan changes, choose based on your risk tolerance and cash-flow needs. Recheck assumptions after major life changes often.
FAQs
What does “allowed charges” mean here?
Allowed charges are the insurer-negotiated in-network amounts for services. Enter your best estimate for coinsurance-based care like labs, imaging, procedures, and hospital bills, not the provider’s sticker price.
Why is “deductible paid” sometimes below the deductible?
If expected allowed charges are lower than the remaining deductible, you cannot pay more than the charges themselves. The model also optionally reduces deductible remaining by copays when that rule applies.
Do copays always count toward the out-of-pocket maximum?
Not always. Some plans count most copays toward the maximum, while others exclude certain categories. Use the “copays count toward OOP maximum” toggle to match your plan’s summary of benefits.
How should I use employer or HSA credits?
Enter annual contributions you can spend on care, such as employer HSA funding. The calculator subtracts credits from total annual cost, helping you compare plans on a net basis.
How can I estimate allowed charges for the year?
Start with last year’s Explanation of Benefits totals, then adjust for planned procedures, therapy, or chronic care. If unsure, test multiple scenarios such as $2,000, $5,000, and $10,000.
What if out-of-network care is likely?
Enable out-of-network charges and enter the expected amount plus OON cost sharing. The calculator models a separate bucket, but real costs can include balance billing, so treat results as conservative.