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Your Medical/Rx Expenses Calculation Sheet
Key Terms to Consider
Copay - Your copay is an amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s
visit, hospital outpatient visit, or prescription drug. A copay is a set amount, rather than a percentage. Copays will only apply if you
are enrolled in the Base or Choice plan.
Deductible - The amount you owe for health care services your health insurance or plan covers before your health insurance or
plan begins to pay. Deductibles apply to all plans. Deductibles do not coordinate or combine between in and out-of-network
services.
Out-of-pocket maximum - Out-of-pocket maximums (OOP) apply to all plans. This is the maximum amount you will pay for health
care costs in a calendar year. If you see an out- of-network provider, you may be responsible for out-of-pocket costs that are
considered above the “reasonable and customary” fees. May include deductibles but not copays.
Coinsurance - Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for service. You
pay co-insurance plus any deductibles you owe.
Please refer to Highmark’s Cost Calculator and MyCareNavigator for help determining potential costs/expenses. These tools
determine whether a copay or deductible or both are applied towards your expenses.
2022 Incurred Medical/Rx Expense Considerations *Key Plan Base Plan Choice Plan
Specialist Office Visits
Office Visit
Office Visit + Lab
Urgent Care Visit
Prescription Drug (Monthly Charges x12)
Total Incurred Expenses
Total Paycheck Deductions (Employee Only) $982 $2,992. $2,035
*Total Amount Saved in HSA ($750/$1,250 employer)
Total Amount Applied to Deductible
Total Subject to Coinsurance
Out of Pocket (OOP) Payment that could be your
Responsibility for Employee/Family care $5,000/$10,000 $3,000/$6,000 $4,000/$8,000
Your HSA Account Balance
Total Employee Cost
Total HSA Savings to Carry over into 2022
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PLEASE NOTE: Employees covered by a collective bargaining agreement should refer to their union agreement to determine if they are eligible for these plans.
