PLAN COST ESTIMATOR
(Annual base pay: $41,000; Family coverage)
Plan Information
PPO
HDHP
$4,944
$1,764
Not applicable
- $1,100
$4,944
$664
# of Primary Care office visits times copay or average cost (HDHP)
5 x $15 = $___
5 x 85= $ ___
# of Specialist office visits times copay or average cost (HDHP)
3 x $20 = $___
4 x 150 = $___
# of Tier 1 Rx times copay (retail/mail order) or average cost (HDHP)
12 x $15/30 = $___
12 x 15 = $___
# of Tier 2 Rx times copay (retail/mail order) or average cost (HDHP)
3 x $25/50 = $___
3 x 50 = $___
# of Tier 3 Rx times copay (retail/mail order) or average cost (HDHP)
4 x $35/70 = $___
4 x 150 = $___
___ x 25%/ $250 max =
$___
___ x ____ = $___
1 x $75 = $___
1 x 900 = $___
Hospital, surgical, other (deductible)
$100/$200 deductible
$1500/$3000
Hospital, surgical, other (co-insurance)
$4850 x 10% = ____
$4850 x 10% = _
Might pay costs cannot exceed amounts to the right (out of pocket max). If higher,
cap costs at this amount.
$1100/$2200
(does not include copays)
$3,000 Single
$6,000 Family
Might pay costs cannot exceed amounts to the right (out of pocket max). If higher,
cap costs at this amount.
$6,850/$13,700
(all expenses, including copays)
All expenses apply to
above max.
Annual Cost of Plan (what you pay out of your paycheck)
Your cost is determined by your annual base pay. ________/mo cost x 12 =
Add cost of Spouse/Domestic partner surcharge, if applicable.
Employer’s HSA Contribution (minus)
1
TOTAL MUST PAY COST (regardless of utilization of plan)
Expenses (Annual) – include yourself plus family members
# of Tier 4 Rx times copay (retail) or average cost (HDHP)
# of emergency room visits or average cost (HDHP)
2
TOTAL MIGHT PAY COST (based on plan utilization)
1+2
TOTAL MUST PAY and MIGHT PAY COST (1 + 2)