Medical Plan Cost Breakdown Calculator

Enter your plan details

Example data table

Formula used

• Annual premium (gross) = Monthly premium × 12
• Net premium = max(0, Annual premium − Employer contribution × 12)
• Copays = (Primary visits × Primary copay) + (Specialist visits × Specialist copay) + (Generic fills × Generic copay) + (Brand fills × Brand copay)
• Deductible paid = min(Deductible, Expected allowed charges)
• Coinsurance paid = max(0, Expected allowed charges − Deductible paid) × Coinsurance rate
• Out-of-pocket before cap = Copays + Deductible paid + Coinsurance paid
• Out-of-pocket after cap = min(Out-of-pocket before cap, Out-of-pocket maximum)
• Total annual cost = Net premium + Out-of-pocket after cap
• Estimated tax savings = HSA/FSA contribution × Marginal tax rate
• Effective annual cost = max(0, Total annual cost − Estimated tax savings)

How to use this calculator

1. Enter your monthly premium and any employer contribution.
2. Fill in deductible, out-of-pocket maximum, and coinsurance rate.
3. Estimate annual usage: visits, prescription fills, and copays.
4. Enter expected allowed charges that will hit deductible/coinsurance.
5. Add your planned HSA/FSA contribution and tax rate estimate.
6. Press Calculate to see the cost summary and breakdown.
7. Use the download buttons to export CSV or PDF.

Planning insights

Why a cost breakdown matters

Medical plans blend fixed premiums with variable out-of-pocket spending. A clear breakdown helps you budget, spot tradeoffs, and avoid choosing a plan based only on the monthly premium. This calculator translates plan rules into expected annual and monthly totals using your own assumptions. It also highlights how employer contributions and tax savings can change the picture dramatically for any household size.

Key drivers: premium, deductible, maximum

Start with the annual premium (monthly premium × 12) and subtract any employer contribution to get net premium. Next, the deductible sets how much you pay before coinsurance applies, while the out-of-pocket maximum caps covered cost sharing. In the default example, a $320 premium and $120 employer share yields $2,400 net premium per year.

Modeling expected usage with allowed charges

Copays are modeled from visit and prescription counts, while “allowed charges” represent services that flow through the deductible and coinsurance. With $4,200 of expected allowed charges and a $1,500 deductible, the model assumes $1,500 paid as deductible and coinsurance on the remaining $2,700. At 20% coinsurance, that adds $540 before applying the maximum.

Using tax-advantaged accounts to reduce cost

If you contribute to an HSA or FSA, your effective cost may drop. The calculator estimates tax savings as contribution × marginal tax rate. For example, a $1,200 contribution at a 22% rate implies about $264 of savings, lowering the effective annual cost without changing the plan’s premium or benefits.

Interpreting results for plan comparison

Use the premium-versus-out-of-pocket split to compare plan designs. Higher-premium, lower-cost-sharing plans often suit predictable, higher usage, while lower-premium, higher-deductible plans may fit low usage with good cash reserves. Run multiple scenarios, export CSV or PDF, and keep your assumptions consistent across plans for a fair comparison.

FAQs

What should I enter for expected allowed charges?

Use your best estimate of covered services that typically apply to deductible and coinsurance, such as imaging, labs, or procedures. If you only expect copay visits, keep this number lower to avoid overstating cost sharing.

Do copays always count toward the out-of-pocket maximum?

Many plans count covered copays toward the maximum, but rules vary. If your plan excludes certain copays, reduce the visit and prescription counts or treat them as separate spending outside the cap.

How does the calculator handle the deductible?

It assumes deductible spending is paid first, up to the deductible amount or your expected allowed charges. After that, coinsurance is applied to the remaining allowed charges until the maximum is reached.

Is the tax savings estimate exact?

No. It is a simple estimate using your marginal tax rate and contribution amount. Actual savings can vary by jurisdiction, payroll setup, eligibility, and contribution limits.

Can I compare two plans with different networks?

Yes, but keep assumptions consistent. If networks change negotiated rates, adjust the allowed charges estimate for each plan. Comparing equal “allowed charges” across plans is a useful starting point.

Does this include premiums taken pre-tax?

Not by default. If your payroll premiums are pre-tax, you can approximate the effect by increasing the tax savings input or reducing the net premium manually, then recalculating for a closer effective cost.