Reviewed September 2026.
The cheapest premium is often the wrong plan. Total cost is premium plus what you will likely pay toward the deductible, copays, coinsurance, and drugs before you hit the out-of-pocket maximum. Use the Summary of Benefits and Coverage (SBC) and a realistic care list, not the monthly line alone. Premium vs deductible tradeoffs: Insurance premiums vs deductibles. Deductible mechanics: Health insurance deductibles.
The four numbers to stack
| Input | Where to find it | What to do with it |
|---|---|---|
| Your share of annual premium | Employer portal or Marketplace quote × 12 | Always include, even in a zero-care year |
| Deductible (in-network) | SBC | Cap of what you pay before many services share cost |
| Expected allowed medical + Rx spend | Your last 12 months of EOBs + drug list | Rough patient share under each plan’s rules |
| OOP max | SBC | Worst-case ceiling for in-network covered care |
Marketplace shoppers should subtract any premium tax credit from the premium column before comparing plans. Employer plans: include only your payroll share, not the employer contribution.
Worked example: two family plans
Aisha compares two in-network Anthem-style options at open enrollment (Open enrollment):
| Plan A (low premium HDHP) | Plan B (higher premium PPO) | |
|---|---|---|
| Aisha’s premium | $280/mo → $3,360/yr | $420/mo → $5,040/yr |
| Deductible | $3,400 | $1,000 |
| Coinsurance after deductible | 20% | 20% |
| OOP max | $7,500 | $5,000 |
| Expected year | 2 specialist visits, 1 imaging, $1,200 allowed Rx | Same |
Rough patient medical/Rx share if allowed non-preventive care totals about $4,000 after preventive $0 services:
| Plan A | Plan B | |
|---|---|---|
| Premium | $3,360 | $5,040 |
| Toward deductible / coinsurance (sketch) | ~$3,400 deductible + 20% of remaining ~$600 ≈ $3,520 | $1,000 + 20% of $3,000 ≈ $1,600 |
| Illustrative total | ~$6,880 | ~$6,640 |
Plan B can win on total cost even with a higher premium. In a preventive-only year, Plan A’s lower premium wins by about $1,680. Run your own numbers; do not copy these.
If Plan A is HSA-eligible, employer HSA seed and tax-advantaged contributions change the math (HDHPs; Use an HSA with an HDHP).
Expected-use worksheet (15 minutes)
- List last year’s visits: PCP, specialists, ER/urgent care, imaging, therapy.
- List monthly scripts with pharmacy retail and plan copay/coinsurance from the formulary tool.
- Flag one “possible big item” (surgery, maternity, new diagnosis) and price it with the plan’s pre-surgery OOP estimate habit.
- For each plan, compute: premium + min(expected patient share, OOP max).
- Prefer the lower total for your care profile, then confirm network and formulary fit.
Checklist
- Never rank plans by premium alone.
- Use the SBC deductible, coinsurance, and OOP max for in-network care.
- Price your real drug list on each formulary.
- Build a light-care and a heavy-care total.
- Re-run every open enrollment; networks and formularies change.
Educational only. Not insurance or tax advice. Plan rules, credits, and IRS HDHP amounts vary by year and issuer.