FLASHP - OOP Cost Estimator - 2026-2027 - CSEA_BP2 Base Fund HSA.xlsx

	A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	W	X	Y	Z	AA	AB	AC	AD
1	Sodus Central School District Out-of-Pocket Cost Estimator - 2026-2027 - CSEA_BP2 Base & Fund HSA																						1 Child
2	Edit BLUE sections in highlighted yellow cells																Before 7 / 1 / 2014						1+ Children
3	Select Contract Tier and HSA Seed:			Base Plan													After 7 / 1 / 2014
4	Family		5	BP2 $20/$20-$10/$25/$40 Rx			HB $15/$25 - $0ded/$500 IP - $5/$25/$50 Rx			HB $30/$50 - $0ded/$500 IP - $5/$35/$70 Rx			Signature $1,800/$3,600 HDHP - 100% HSA Seed			6	BP2 $20	HB $15	HB $30	HDHP $1,800/$3,600	HDHP $3,500/$7,000	HDHP $5,500/$11,000
5	Please select 1 or 1+children:	1 Child	39	Type of Plan:		BluePoint	Type of Plan:		HealthyBlue Copay	Type of Plan:		HealthyBlue Copay	Type of Plan:		HDHP
6				If HDHP, seed:		No Seed	If HDHP, seed:		No Seed	If HDHP, seed:		No Seed	If HDHP, HSA Seed		$3,600
7	2026-2027 Annual Premium			$39,199			$41,758			$38,474			$29,219

8	Annual Deductible			In-Network		$0	In-Network		$0	In-Network		$0	In-Network		$3,600
9	Annual Deductible			Out-of-Network		$1,250	Out-of-Network		$1,500	Out-of-Network		$1,500	Out-of-Network		$3,960
10	Annual Out-of-Pocket Maximum			In-Network		$12,700	In-Network		$12,600	In-Network		$12,600	In-Network		$7,200
11	Annual Out-of-Pocket Maximum			Out-of-Network		$12,700	Out-of-Network		$13,860	Out-of-Network		$13,860	Out-of-Network		$7,920
12	Coinsurance (after deductible)			N/A			N/A			N/A			20%
13	Sodus Contribution Towards Premium %			80%			75%			82%			95%
14	Sodus Contribution Towards Premium $			$31,359			$31,359			$31,359			$27,759
15	Out-of-Pocket Expense Description	Est. Actual Cost Per Unit	Quantity Per Year	Unit Cost	Quantity Per Year	Total	Unit Cost	Quantity Per Year	Total	Unit Cost	Quantity Per Year	Total	Unit Cost	Quantity Per Year	Total
16	Payroll deduction for premium		20	$392	20	$7,840	$520	20	$10,399	$356	20	$7,114	$73	20	$1,460
17	Annual physical exam (1/year per adult)	$150	2	$0	2	$0	$0	2	$0	$0	2	$0	$0	2	$0							Annual physical exam (ADULT)	6
18	Well child primary care visit (CHILD)	$100	2	$0	2	$0	$0	2	$0	$0	2	$0	$0	2	$0							Well child primary care visit (CHILD)	7
19	Diagnostic primary care visit (ADULT)	$100	4	$20	4	$80	$15	4	$60	$30	4	$120	$100	4	$400							Diagnostic primary care visit (ADULT)	8
20	Diagnostic primary care visit (CHILD)	$90	4	$20	4	$80	$15	4	$60	$30	4	$120	$90	4	$360							Diagnostic primary care visit (CHILD)	9
21	Specialist visit	$180	4	$20	4	$80	$25	4	$100	$50	4	$200	$180	4	$720							Specialist visit	10
22	Outpatient surgery (facility)	$2,700	1	$50	1	$50	$75	1	$75	$250	1	$250	$2,700	1	$2,700							Outpatient surgery (facility)	12
23	Freestanding urgent care center visit	$250	6	$25	6	$150	$25	6	$150	$50	6	$300	$250	6	$1,500							Freestanding urgent care center visit	14
24	Tier 1 Prescription Drugs (Generic) - Kids*	$20	18	$10	18	$180	$0	18	$0	$0	18	$0	$20	18	$360							*Tier 1 Prescription Drugs CHILD (Generic)	15
25	Tier 1 Prescription Drugs (Generic)* - Adults	$20	6	$10	6	$60	$5	6	$30	$5	6	$30	$20	6	$120							*Tier 1 Prescription Drugs ADULT (Generic)	16
26	Tier 2 Prescription Drugs (Preferred brand)*	$340	2	$25	2	$50	$25	2	$50	$35	2	$70	$340	2	$680							*Tier 2 Prescription Drugs (Brand name, less expensive)	17
27	Tier 3 Prescription Drugs (Non-Preferred brand)*	$340	2	$40	2	$80	$50	2	$100	$70	2	$140	$340	2	$680							*Tier 3 Prescription Drugs (Brand name, more expensive)	18
28	Tier 1 Prescription Drugs (Preventive)*	$20	18	$10	18	$180	$5	18	$90	$5	18	$90	$5	18	$90							Tier 1 Prescription Drugs (Preventive)*	19
29	Tier 2 Prescription Drugs (Preventive)*	$340	3	$25	3	$75	$25	3	$75	$35	3	$105	$35	3	$105							Tier 2 Prescription Drugs (Preventive)*	20
30	Tier 3 Prescription Drugs (Preventive)*	$340	0	$40	0	$0	$50	0	$0	$70	0	$0	$70	0	$0							Tier 3 Prescription Drugs (Preventive)*	21
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32	SUBTOTAL					$8,905			$11,189			$8,539			$9,175
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34	Employee's Share of Premium					$7,840			$10,399			$7,114			$1,460
35	Subject to Deductible					$0			$0			$0			$3,600
36	Employee's Share of Coinsurance (costs above deductible)					$0			$0			$0			$823
37	Employee's Actual Costs (subject to Out-of-Pocket max)					$8,905			$11,189			$8,539			$5,883
38	Minus District Contribution to Health Reimbursement Account (HRA)					$0			$0			$0			$0
39	Minus District Contribution to Health Savings Account (HSA)**				No Seed	$0		No Seed	$0		No Seed	$0		100% HSA Seed	$3,600
40	Employee's Actual Out-of-Pocket Costs***					$8,905			$11,189			$8,539			$2,283
41	Employee HSA Balance Remaining														$0
42	Sodus CSD Premium + HSA Annual Cost					$31,359			$31,359			$31,359			$31,359
43	All estimates based upon in-network services.												HDHP Savings for Sodus		$0
44	The HDHP deductible is based on a calendar year enrollment and any deviations to this (included meeting multiple deductibles in a plan year) are not factored into this estimator.												HDHP Savings for Sodus		$0
45	*HDHP prescription costs switch to copayments once deductible is met. Actual Rx costs may be more or less depending on order of claims.
46	**Contributions into HSA are made once during the year (January)
47	***Out-of-Pocket costs may vary greatly depending on the order of services throughout the year. Amounts shown are examples based on informed estimates. Actual costs will vary.
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