How do I choose a tier?

Insurance companies assign drugs to different pricing tiers based on the drug's price and then use those tiers to determine your co-pay. Tier 1 is for the least expensive generic drugs. Tier 2 is for the branded drugs on the insurance plan's "formulary." Generally these are branded drugs that have been available for a long time. Tier 3 is for costly branded drugs that aren't in the plan's formulary. Tier 4 is for the most costly speciality medications.

How Should I Treat Out of Network Care?

Unfortunately, insurers take varying approached to what they'll pay if you you get your care from outside their network of preferred providers. The variety of apporaches makes it impossible for us to include them all in our calculations. We suggest you take on of two approaches:

  1. Resolve that you'll always use their In-Network providers for your care. In that case, our calculator works fine.
  2. Assume the worst case scenario that you'll pay 100% for your Out of Network Care. Make a tally of that expense and add it to the Out of Wallet total that we calculate for you.

How Can I Estimate Costs?

Accurately anticipating the costs of different doctor visits and medical procedures is one of the most confounding issues in American healthcare. There isn't much "price transparency" and doctors' offices often seem unwilling or unable to talk about their rates. We suggest the following:

  1. If you've been insured before, look at your old "Explanations of Benefits." Those are the statements that come in the mail from your insurer after a doctor visit. Look up the amount that the insurer paid the doctor. Use that amount.
  2. Phone your doctor's office and ask them the rate they're typically reimbursed by an insurance plan for the kind of visit or procedure you're anticipating.
  3. Do some online research. Look for online resources that are publishing the rates for different procedures. Here are a few examples. Choose the rates that insurers are paying for the procedures. (Unless you're trying to estimate an Out of Network expense. In that case, use the Cash Pay cost.)
  4. If you can't come up with any better estimates, use our default estimates that primary care appointments cost about $150 and specialty appointments cost about $350.
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