| Name | Unit price | Units/fill | Fills/year | Tier multiplier | Start month |
|---|---|---|---|---|---|
| Plan design | Premium | Deductible | Copay | Coinsurance | Coverage % | OOP Max |
|---|---|---|---|---|---|---|
| Low premium, higher sharing | $240 | $500 | $0 | 30% | 90% | $3500 |
| Balanced plan | $420 | $250 | $15 | 20% | 100% | $2000 |
| Higher premium, lower copay | $720 | $0 | $10 | 10% | 100% | $1500 |
- Add medications: enter name, price, units, refills, tier, and start month.
- Set plan rules: deductible, cost sharing, coverage percent, and discounts.
- Add advanced options: coupons, tax, copay bounds, and gap rules.
- Calculate: review totals, monthly tables, and graphs.
- Export: download CSV for analysis or PDF for sharing.
Prescription cost drivers and inputs
Annual spending depends on three data points: unit price, units per fill, and fills per year. This calculator multiplies them, then applies tier multipliers, network or mail-order discounts, and dispensing fees. When inflation is set, later months rise by a proportional factor, improving budget realism. Enter multiple medications to model combined exposure, not a single drug snapshot. For example, raising tier from 1.00 to 1.35 increases gross cost by 35%, before discounts, and the tables reveal how quickly limits are reached for you.
Deductible and cost-sharing behavior
Deductible is applied to the covered portion first, then the remaining covered amount is split by copay, coinsurance, or hybrid rules. Optional copay minimum and maximum clamps simulate plans that enforce floors or ceilings per fill. The monthly table shows deductible remaining and cumulative out-of-pocket progression, helping identify when cost-sharing shifts during the year.
Coverage percent, uncovered amounts, and caps
Coverage percent models partial benefit coverage where some spending is not eligible for insurer sharing. Uncovered cost is member-paid immediately, while covered cost is shared. The out-of-pocket maximum can cap member payments, and an optional insurer payment cap can shift excess coverage back to the member. Two toggles control whether uncovered amounts and coupons are counted toward out-of-pocket tracking.
Coupons, taxes, and export-ready outputs
Per-fill coupons reduce member payments and can be set to count or not count toward out-of-pocket calculations. A member tax rate can be applied after coupon credits to approximate sales tax or fees where applicable. Results export as CSV for analytics and as PDF for sharing, including medication and monthly summaries for audit-friendly review.
Interpreting graphs for plan comparison
The pie chart separates member paid, insurer paid, and premium. The stacked bar chart shows monthly member and insurer amounts with coupon credits. The dual-axis line chart plots cumulative out-of-pocket against deductible remaining. Compare scenarios by adjusting premium, deductible, cost-sharing, and discounts; the best plan is often the lowest member total, not the lowest premium.
FAQs
1) What does “coverage percent” represent?
It represents the portion of each fill treated as eligible for insurer sharing. The remaining portion is treated as uncovered and is member-paid immediately in this model.
2) When should I use hybrid cost sharing?
Use hybrid when a plan applies copay or coinsurance, whichever is higher. It helps model specialty tiers where coinsurance can exceed a flat copay.
3) Why are coupons handled separately from insurer payments?
Coupons are credits that reduce member payment, not insurer liability. The coupon toggle lets you decide whether pre-coupon or post-coupon amounts count toward out-of-pocket tracking.
4) Does the out-of-pocket maximum stop all costs?
It caps member cost sharing in the calculator once reached, then shifts covered cost to the insurer. Real-world policies may exclude non-covered items or certain fees.
5) How does the coverage gap option work here?
After cumulative gross drug cost crosses the threshold, the calculator switches the member share of covered costs to the configured gap percentage until year end.
6) What is the best way to compare two plans?
Run each plan with the same medication rows and assumptions. Compare “Member total (paid + premium)” and review the monthly charts to see timing of deductible and out-of-pocket limits.