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Member Out-of-Pocket Cost Estimate Tool

The new Member Out-of-Pocket Cost Estimate tool calculates the approximate cost share of a medical procedure or service. The tool incorporates a patient's benefits, copayments, coinsurance and deductible information to show the approximate costs associated with a particular procedure or service.


How the Tool Works


Cost estimates are developed using 12 months of claims data (six months for office-based services) and are based on rates for all facilities within the Blue Cross® and Blue Shield® national network. A procedure or service includes the cost of a complete episode of care. That means all of the hospital, physician and other ancillary costs related to treating that condition are included within the estimate.


Once a cost estimate is developed, a patient's specific benefit accumulations are applied. Please keep in mind that this tool takes a member's specific benefit accumulation for that point in time. Therefore, his or her coinsurance, deductible and out-of-pocket maximum accumulation could be different from the day the estimate was generated and the actual day of service.


For additional information, please refer to this Q&A document.


How Can Providers Access the Tool?


The cost estimates are only available through a secure website hosted by the Blue Cross and Blue Shield Association. Access is limited to members whose Blue Plan has chosen to display the data and manage access from their sites. Providers may view these estimates only if they themselves have a Blue Plan with access to the data.

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