Summary of Benefits and Coverage

---

Overview

Starting Screen
Manual Entry

---

Sheet 1: Starting Screen

Welcome to the Coverage Scenarios Cost Sharing Calculator

All insurer data entry fields will be highlighted in orange:

There are two methods to use this tool:

AUTOMATED

Imported data from a Comma Separated Value (CSV) file

You can process multiple plans at one time with this method

MANUAL

Manually enter information about one plan

How would you like to use the tool?

Automated

---

Sheet 2: Manual Entry

	MANUAL ENTRY INSTRUCTIONS									Switch to:
	Fill in the coverage details for one plan in the orange cells using numbers only.
	If the category is not covered or included in the plan, leave the cell blank.
	Click the 'Run the Calculator' button to compute the cost sharing for the scenarios.
									Selection	$ OR %
		COST SHARING		Durable Medical Equipment					No Cost Sharing
				Generic Prescriptions					Copayment	$10
				Hospital Care, Inpatient & Anesthesia					Coinsurance	30%
				Laboratory					No Cost Sharing
				Radiology (Ultrasound)					Coinsurance	30%
				Routine Obstetric Care (Bundled)					Copayment	$40
				Vaccine & Preventive					No Cost Sharing
				Visits & Procedures					Copayment	$40
				Individual Out-of-Pocket (OOP) Limit
		DEDUCTIBLES		Overall Plan Deductible						$1,000
				Durable Medical Equipment
				Generic RX						$100
				Hospital Care, Inpatient & Anesthesia
				Routine Obstetric Care (Bundled)
				Vaccine & Preventive
		LIMITS	MATERNITY	Generic Prescriptions # Limit Per Month
				Generic Prescriptions # Limit Per Year
			DIABETES	Generic Prescriptions # Limit Per Month
				Generic Prescriptions # Limit Per Year
				Durable Medical Equipment # Limit Per Month
				Durable Medical Equipment # Limit Per Year
				Visits & Procedures # Limit Per Year