When you see a doctor, the provider bills a total amount — that's the claim. It's not what you owe; it's the full cost before your insurance steps in. Pick an example below and see how each plan tier splits that bill between you and your insurer.
Select a common medical event to see the total billed cost — then watch how each plan handles it.
Per individual. Family plans have a separate, higher limit that caps total spending across all covered members.
Per individual. Family plans have a separate, higher limit that caps total spending across all covered members.
Per individual. Family plans have a separate, higher limit that caps total spending across all covered members.
Per individual. Family plans have a separate, higher limit that caps total spending across all covered members.
What you pay out of pocket before insurance starts sharing the bill. A Bronze plan has a higher deductible but a lower monthly premium — you're betting on staying healthy.
Once you've met your deductible, you and your insurer split what's left. “20% coinsurance” means you pay 20 cents on the dollar; insurance picks up the other 80.
Your yearly ceiling. After you've paid this much in deductibles, copays, and coinsurance, insurance covers everything else at 100%. Family plans have two limits: one per individual member, and a higher one for the family as a whole. Once the family limit is reached, everyone is covered — even if some members haven't hit their individual cap.
A flat fee for routine services — doctor visits, urgent care, prescriptions. Copays skip the deductible entirely: you pay the copay and insurance handles the rest. Try “Doctor Visit” above to see the difference. Bigger-ticket services like ER visits and surgery still go through the deductible.
Annual checkups, screenings, and immunizations are 100% covered under the ACA — no copay, no deductible, no matter which plan tier you're on. It's one of the most underused benefits in health insurance. Try “Annual Checkup” above.
Lower premiums mean higher costs when you actually need care; higher premiums mean lower costs at the doctor's office. There's no universally “best” plan — the right choice depends on how much care your team expects to use.
Most plans tier medications separately from medical services. Here's what a typical fill looks like across plan levels.
| Drug Tier | Bronze | Silver | Gold | Platinum |
|---|---|---|---|---|
| GenericMetformin, Lisinopril, Atorvastatin | $20 | $20 | $15 | $10 |
| Preferred BrandEliquis, Jardiance, Ozempic | 40%* | $75 | $50 | $25 |
| Non-Preferred BrandBrand-name with no generic equivalent | 40%* | $105 | $80 | $40 |
| SpecialtyHumira, Stelara, chemotherapy drugs | 40%* | 30% | 20% | 10% |
| Rx DeductibleApplies to brand-name drugs before copay kicks in | $450 | $300 | — | — |
*Bronze coinsurance: Bronze plans charge a percentage (40%) instead of a flat copay for brand-name and specialty drugs. Your cost depends on the drug's price — a $200 brand-name drug costs you $80; a $1,000 specialty drug costs $400.
Generic vs. Brand: Always ask your doctor about generics. The same active ingredient can run $10–$20 as a generic vs. $50–$105 as a brand name — that's $400+ per year in savings on a single prescription.
Rx Deductible: Bronze ($450) and Silver ($300) plans have a separate prescription deductible for brand-name drugs. Generics are usually exempt. Once you've met it, your normal copays or coinsurance kick in for the rest of the year.
Specialty drugs: Every tier uses coinsurance for specialty medications, capped at $250–$500 per fill. If you take a specialty drug, Platinum (10%) saves significantly over Bronze (40%) despite the higher premium.
We'll walk through your group's needs and find the right balance of premium and protection.
Talk to a Broker →The numbers above are based on Blue Shield PPO plan designs available through Covered California for Small Business. They illustrate how cost-sharing works in general — actual benefits vary by carrier, plan, and network type. Routine services like doctor visits and urgent care typically use a flat copay that bypasses the deductible; try those presets above to see the difference. HMO plans and other carriers may structure things differently. Contact us for specifics on plans available to your group.