HOW THE MEDICAL PLAN MODELER WORKS

To estimate your out-of-pocket costs for 2025, the Medical Plan Modeler assumes the following:

• Expense estimates are based on information you enter about your expected medical and prescription drug use in 2025. The modeler uses 2025 premiums, deductibles, copays, coinsurance rates, and out-of-pocket maximums.
• The results shown here are based on the information you provide and reflect the benefit you could receive from MSK's different medical plans. The assumptions about your healthcare needs, based on the information you provide, might differ from your actual experience and circumstances, and that difference could be substantial.
• You (and any eligible dependents) are enrolled for all of 2025 in one of the available medical options.
• You have followed all of the protocols required by the medical and prescription plans (such as prior authorization).
• You are using the Express Scripts Smart 90 Program for maintenance medications and only filling through the approved pharmacies.
• The average prescription costs are the average costs of retail and mail-order prescription drugs paid through the MSK plan. Specialty drugs are not included because their costs vary widely.
• The modeler calculates values according to the varying provisions associated with each medical option.
• For plans with a separate prescription drug out-of-pocket maximum, the modeler calculates your costs by assuming that healthcare is received in the following order: preventive care, primary care physician office visits, specialist office visits, urgent care visits, Emergency Room visits, outpatient surgery, inpatient hospital stays, and other medical expenses. The UnitedHealthcare (UHC) CDHP’s deductible includes prescription drug costs; for this plan, the modeler assumes that 70% of any prescription costs are incurred before a user is hospitalized.
• For the United Healthcare (UHC) Tiered EPO, the modeler assumes you use only Tier 1 providers. You’ll pay more for some covered services if you do not use a Tier 1 provider.
• If you are covering dependents and choose to model your own usage, the modeler assumes that visits are distributed among users. For example, if you are covering two dependents and enter five specialist office visits, the modeler would assume two visits for the first user, two visits for the second user, and one visit for the third user. If you choose to model a scenario, the modeler distributes visits as indicated in the scenario’s description.
• Visits to the Emergency Room are for true emergencies, and hospitalizations (including hospitalization for maternity) have been pre-approved by the plan administrator.
• No IRS-approved change in status events occur in 2025. A change in status event — for example, birth, adoption, or marriage — would likely affect your actual costs in 2025, but will not be reflected in your cost estimates.
• Results are rough estimates. Actual medical and prescription drug use and costs will vary from the modeler results, and the actual benefits you receive will be determined by the claims administrator, administered in accordance with the plan and any underlying agreement and contracts, including: negotiated pricing for in-network services; use of out-of-network services; amounts subject to fee limits for out-of-network use; and other plan limits and exclusions.
• Any imputed tax implications of covering a domestic partner are not included in calculations if you indicate you will cover dependents.
• Information you enter into this tool is used solely to assist you in deciding which medical plan you may want to consider in 2025.
• To protect your privacy, individual identifiable entries are not tracked; your information will not be stored, shared, or distributed.
• This modeler can serve as a general decision-making guide but should not be strictly relied upon as a predictor of future medical and prescription drug use, costs, or benefits.
• Neither this Medical Plan Modeler nor any information contained on this website constitutes tax, legal, or planning advice and cannot be relied upon for such a purpose. Where specific advice is necessary or appropriate, please consult a qualified tax advisor, financial planner, or other professional.
• Benefits ultimately payable to you will be determined in accordance with the legal plan documents in effect and applicable law. The modeler is not intended to, and cannot be relied upon to, interpret, extend, or change any MSK benefit program in any way.