Enter claim and plan details
Tip: If you have the insurer’s “allowed amount,” use that instead of the provider’s full charge for a closer estimate.
Example data table
| Scenario | Total billed | Patient pays | Plan pays | Notes |
|---|---|---|---|---|
| Office Visit | $180.00 | $35.00 | $145.00 | Covered-only scenario |
| Lab Work | $1,010.00 | $570.00 | $440.00 | Includes non-covered charges |
| Imaging | $2,400.00 | $1,402.50 | $997.50 | Covered-only scenario |
| Procedure (Near OOP Max) | $5,400.00 | $550.00 | $4,850.00 | Includes non-covered charges |
Examples are illustrative and use the same calculator logic as the form.
Formula used
The calculator splits the allowed claim amount into patient and plan shares, then adds any non-covered amount to the patient total.
- Copay applied = min(copay, remaining allowed amount)
- Deductible paid = min(deductible remaining, remaining allowed amount)
- Coinsurance paid = remaining allowed amount × (coinsurance %)
- Patient covered cost = copay + deductible paid + coinsurance paid
- OOP max protection applies when counting costs exceed your remaining cap
- Plan pays = allowed amount − patient covered cost
- Patient total = patient covered cost + non-covered amount
If you enter an out-of-pocket maximum remaining, the calculator reduces only the costs that count toward that cap (deductible, coinsurance, and optionally copay), and shifts the excess to the plan payment.
How to use this calculator
- Enter the allowed (covered) claim amount for the service.
- Add any non-covered charges you expect to pay in full.
- Fill in your remaining deductible, copay, and coinsurance percent.
- Optionally enter your remaining out-of-pocket maximum for the year.
- Pick the cost order that matches your plan’s benefit rules.
- Click Calculate to see totals and a detailed breakdown.
- Use Download CSV or Download PDF to save results.