How to Use the Calculator
To estimate your yearly out-of-pocket costs, use the calculator below. It's easy:
1. Just fill in the funding amount of your Blue Care® Account in whole dollars.
2. Estimate the medical and pharmacy services you think you'll need in the upcoming year. Not sure what a term means? Just click on the service and our glossary will explain more.
3. Click "Get Out-of-Pocket Costs" to see what your out of pocket costs might be once you have used up your Blue Care Account funds.


Plan Information
 
Benefit Plan:    
 (plan name can be found on your ID card)
Type of Coverage:    
Blue Care Account Funding:   $
(e.g., 500,1250)

Services
In the blue box below, fill in the fields with the appropriate number of services you think you will need this year, and we’ll calculate your estimated out-of-pocket cost based on you’re your Blue Care® Account balance. You may edit the Cost of Services* amount to reflect your actual costs.
 Medical Services Per YearNumber of
Services		Estimated Cost
per Service*		Total Cost
 Inpatient Admission (non-Maternity)$$
 Inpatient Admission (Maternity)$$
 Inpatient Admission (Behavioral Health)$$
 Outpatient Surgery$$
 Emergency Room Care$$
 Preventive Office Visit / Physical Exam$$
 Non-Preventive / Diagnostic Office Visit$$
 Behavioral Health Office Visit$$
 High-Tech Radiology (e.g. MRI, CAT Scan, PET scan)$$
 Other Diagnostic Labs and Tests$$
 Vision Exam$$
 Physical Therapy$$
 Chiropractic Care$$
  

Total Estimated Medical Services Costs:


$
*The cost per service is based on State of Massachusetts averages. For a specific amount, refer to your claims history at Member Self Service or call your provider.
Prescriptions
In the blue box below, fill in the fields with the appropriate number of prescription types you think you will need this year, and we’ll calculate your estimated out-of-pocket cost based on you’re your Blue Care® Account balance. You may edit the Cost of Services* amount to reflect your actual costs.
 Prescriptions Per YearNumber of Rx Fills per YearCost per Prescription**Total Cost
 Brand Name
(Retail - 30 day supply)		$$
 Generic
(Retail - 30 day supply)		$$
 Brand Name
(Mail Order - 90 day supply)		$$
 Generic
(Mail Order - 90 day supply)		$$
  

Total Estimated Prescription Costs:


$
**This information is provided for educational purposes only. Prices are based on average wholesale price (AWP) and estimated average industry discounts as of January 2004. Your actual cost depends on your specific prescription medication benefit as described in your health plan and the specific price charged by your pharmacy.
Want to track your claims, deductibles, and have access to detailed benefit information? Then register for Member Self Service at bluecrossma.com. In addition to claims and benefit information, most members can also update their primary care physician, order ID cards, and access MyBlueHealth, our comprehensive online lifestyle management tool.



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