Total Health Plan Calculator

Calculator Inputs

Plan name

Coverage type

Pay frequency

Employee premium (per pay period)

Your payroll deduction amount.

Employer premium (per pay period)

Used to show employer and combined costs.

Network scenario

Out-of-network often costs more.

In-network cost sharing

Deductible (annual)

Out-of-pocket max (annual)

Coinsurance (member % after deductible)

Out-of-network cost sharing

Deductible (annual)

Out-of-pocket max (annual)

Coinsurance (member % after deductible)

Allowed-cost multiplier

Scales allowed spend for out-of-network estimates.

Copays and prescriptions

Primary care copay

Specialist copay

Urgent care copay

ER copay

Generic Rx copay

Preferred brand Rx copay

Non-preferred brand Rx copay

Specialty Rx pricing mode

Specialty coinsurance %

Specialty copay (per fill)

Specialty subject to deductible?

If no, specialty uses coinsurance only.

Annual utilization estimates

Primary care visits

Specialist visits

Urgent care visits

ER visits

Avg allowed cost per PCP visit (optional)

Avg allowed cost per specialist visit (optional)

Avg allowed cost per urgent visit (optional)

Avg allowed cost per ER visit (optional)

Labs allowed spend (annual)

Imaging allowed spend (annual)

Procedures/hospital allowed spend (annual)

Generic Rx fills (annual)

Preferred brand fills (annual)

Non-preferred brand fills (annual)

Specialty Rx fills (annual)

Specialty allowed spend (annual)

Tax-advantaged contributions (optional)

HSA employee contribution (annual)

FSA employee contribution (annual)

Employer HSA contribution (annual)

Marginal tax rate (0–0.60)

Used for contribution tax savings estimate.

Model settings

Copays count toward OOP max?

Apply coinsurance above copay using averages?

Use avg allowed costs to model extra cost above copays.

Example Data Table

Scenario	Employee premium / month	Deductible	OOP max	Coinsurance	Visits (PCP/Specialist)	Allowed spend (labs/procedures)	Estimated net employee cost
Low usage	$180	$1,500	$6,000	20%	1 / 1	$150 / $0	$2,460
Typical year	$180	$1,500	$6,000	20%	2 / 2	$250 / $800	$4,160
High utilization	$180	$1,500	$6,000	20%	4 / 6	$600 / $8,000	$8,160
Out-of-network sample	$180	$3,000	$12,000	40%	2 / 2	$250 / $800	$5,420

Numbers above are illustrative examples to guide data entry.

Formula Used

Annual premiums: employee_premium × pay_periods_per_year (employer premiums calculated similarly).
Deductible phase: member pays allowed costs until deductible is met.
Coinsurance phase: after deductible, member_share = allowed × coinsurance%.
Copays: fixed amount per visit or prescription, optionally counted toward OOP max.
Out-of-pocket cap: member medical+Rx spending is capped at the plan OOP max.
Tax savings estimate: (HSA + FSA) × marginal_tax_rate.
Net employee cost: employee_premiums + OOP − tax_savings − employer_HSA.

Tip: Enable “Apply coinsurance above copay” and enter average allowed costs if your plan charges copay plus coinsurance for certain services.

How to Use This Calculator

Enter your plan premiums and select your pay frequency.
Fill in deductible, coinsurance, and out-of-pocket maximum values.
Enter copays and prescription tiers from your benefits summary.
Estimate annual utilization: visits, lab spend, imaging, procedures, and prescriptions.
Optional: add HSA/FSA contributions and your marginal tax rate.
Click “Calculate” to see totals and a detailed breakdown.
Use CSV/PDF buttons to export and share your estimate.

Premium timing and annualization

Premiums are converted to annual totals using pay periods. Weekly uses 52, biweekly 26, semi-monthly 24, monthly 12, and annual 1. If your employee premium is $180 monthly, annual premiums equal $2,160. Employer premiums are tracked separately to show combined plan cost.

Deductible and coinsurance mechanics

Allowed medical spending is applied to the deductible first. Once the deductible is met, the remaining allowed amount is multiplied by the member coinsurance rate. Example: $1,500 deductible and 20% coinsurance on $3,000 allowed spend yields $1,500 deductible plus $300 coinsurance, or $1,800 member cost. If you enable coinsurance above copay, the model can estimate copay plus coinsurance designs using average allowed visit costs.

Out-of-pocket maximum behavior

The out-of-pocket maximum caps eligible member spending during the year. The calculator can count copays toward the cap, mirroring many plan designs. When the cap is reached, additional eligible services add $0 to member cost, preventing unrealistic totals in high utilization scenarios. The output reports deductible used, so you can see when spending shifts from deductible to coinsurance.

Prescription tiers and specialty exposure

Copays are estimated by tier using annual fill counts for generic, preferred brand, and non-preferred brand drugs. Specialty medications can be modeled as coinsurance on allowed spend or a per-fill copay. If specialty spending is subject to the deductible, early-year costs rise sharply. A $10,000 specialty allowed spend at 30% coinsurance produces $3,000 member cost, subject to the out-of-pocket cap.

Interpreting net cost outputs

Net employee cost equals employee premiums plus estimated out-of-pocket, minus tax savings from HSA or FSA contributions, minus any employer HSA contribution. Review the waterfall chart to see which component dominates. Use the in-network or out-of-network toggle to stress test pricing; the out-of-network allowed-cost multiplier scales allowed spending. Compare scenarios by changing utilization, then export CSV or PDF for benefits discussions.

FAQs

Does this calculator replace a carrier quote?

No. It estimates costs from your inputs and typical plan mechanics. Actual claims depend on contracted rates, benefit carve-outs, prior authorization, and how services are coded and billed.

How do I estimate allowed spending for labs, imaging, and procedures?

Use prior-year explanation-of-benefits totals, a provider estimate, or your plan’s cost estimator. Enter allowed amounts, not billed charges, and keep conservative ranges when you are unsure.

What does the out-of-network allowed-cost multiplier do?

It scales your allowed spending to reflect higher prices and weaker discounts out of network. It is a sensitivity lever, not a prediction of balance billing, which can vary by provider and law.

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

Not always. Many plans include copays, but some exclude certain copays or pharmacy costs. Use your summary of benefits to decide, then set the toggle to match your plan.

How are HSA and FSA tax savings calculated?

The tool multiplies employee contributions by your marginal tax rate. It is a simplified estimate and does not model payroll taxes, limits, carryovers, or eligibility rules for each account type.

What is the best way to compare two plans using this tool?

Run the same utilization assumptions for each plan, then test low, typical, and high scenarios. Focus on net employee cost, out-of-pocket exposure, and whether the OOP maximum is reached.