Benefits Investigation Cost Summary
What a patient will pay for a therapy under the plan found in a benefits check.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Allowed amount per administration
- 4000 USD
- Administrations in the plan year
- 13
- Deductible still to meet
- 1500 USD
- Out-of-pocket maximum still to meet
- 5000 USD
- Coinsurance or copay
- Coinsurance (percent)
- Coinsurance percent or copay dollars
- 20
Result: Patient pays $2,000.00 for the first administration, $4,400.00 over the first 90 days, and $5,000.00 for the plan year.
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Allowed amount per administration
- Administrations in the plan year
- Administrations in the first 90 days
- Deductible still to meet
- Out-of-pocket maximum still to meet
- Coinsurance or copay
- Coinsurance percent or copay dollars
- Prior authorization required
- Specialty pharmacy required
How this is calculated
Citation
Walks the plan's deductible, coinsurance or copay and out-of-pocket maximum as a claim adjudicates, from the reader's benefits check; a non-grandfathered plan's out-of-pocket maximum caps in-network cost sharing (45 CFR 156.130). Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.