Gene Therapy Out-of-Pocket Forecaster

Translate seven-figure gene therapy pricing into clear patient cash exposure. Provide the allowed charge, your coinsurance percentage, and the out-of-pocket maximum remaining to see what you personally owe versus what the insurer pays. Optional deductible and manufacturer-assistance fields show how support programs or unmet deductibles shift the final invoice.

Use the negotiated amount from the facility or specialty pharmacy.
Patient share applied after the deductible has been met.
Include any amounts already paid this plan year to reflect remaining exposure.
Defaults to $0. Enter the deductible portion that still needs to be satisfied before coinsurance applies.
Defaults to $0. Include copay programs or patient support grants tied to the therapy.

Insurance plan rules vary. Confirm benefit design, accumulator tracking, and assistance eligibility with your health plan administrator before committing funds.

Examples

  • $2,100,000 charge, 20% coinsurance, $9,000 OOP max, $1,000 deductible remaining, $5,000 assistance ⇒ Patient pays $4,000.00 USD after assistance (0.19% of treatment cost) • Insurer covers $2,091,000.00 USD • Manufacturer assistance applied: $5,000.00 USD • Out-of-pocket maximum is reached for the year.
  • $850,000 charge, 30% coinsurance, $12,000 OOP max, deductible blank, assistance blank ⇒ Patient pays $12,000.00 USD after assistance (1.41% of treatment cost) • Insurer covers $838,000.00 USD • Manufacturer assistance applied: $0.00 USD • Out-of-pocket maximum is reached for the year.

FAQ

How do I include travel or lodging stipends?

Add those costs manually after running the calculator—the tool focuses on medical billing exposures. Use the result to budget separately for ancillary travel needs.

Can I model multiple gene therapy doses?

Yes. Multiply the allowed charge by the number of doses before entering the figure so the coinsurance and out-of-pocket tracking include every administration.

What if reinsurance picks up part of the claim?

The insurer payment shown is the gross plan liability. Carve-outs such as reinsurance or stop-loss arrangements do not change the patient-facing amounts.

Does the calculator assume the deductible resets?

No. Enter the remaining deductible for the current plan year. The tool assumes everything occurs in the same benefit period.

Additional Information

  • Coinsurance is applied after the deductible portion you enter has been satisfied, reflecting typical PPO and specialty pharmacy workflows.
  • The patient share is capped at the remaining out-of-pocket maximum so you can confirm whether the catastrophic limit will be met by this single claim.
  • Manufacturer support is treated as cash applied directly to the patient portion; if support exceeds the balance, the tool floors your payment at $0.00.

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