Health insurance costs can differ, but there are some basics that you should know no matter what plan you have:

  • What kind of fees you might have to pay
  • What to do if you do not think you can afford a plan
  • Choosing a plan based on how much it might cost

What kind of fees might I have to pay?

You will have to pay for different services. Some costs will be expected, but others can catch you by surprise.

Health insurance is a way to spread out and share the costs of health care so you can afford to get care when you need it.

Tracking your health expenses this year can help you prepare for next year.

Every month you pay a premium to have health insurance even if you do not get care or use the insurance.

A deductible is the amount you must pay for care each year before insurance begins sharing the cost. Your deductible might be $1,000. That means you pay all of the cost of care until you reach that amount, but there might be some services where a deductible does not apply.

A smaller, fixed amount for services is called a copay. If your plan has a deductible, the copay is what you’ll pay for service after meeting your deductible. However, some plans use copays for things like doctor’s appointments or prescription medicines even before your deductible is met.

For some services, you will pay a percentage (%) of the total cost of care and your insurance will pay the rest. This is called coinsurance. If your coinsurance for hospital care is 20%, it means you will pay for 20% of the cost, and your plan will pay the other 80%. If your plan has a deductible, the coinsurance is what you’ll pay for some services after meeting your deductible.

There is a limit on the amount of money you or your family will have to pay each year for covered services, called an out-of-pocket maximum. After that, your insurance pays the full amount of covered medical costs for the rest of the year.

  • For 2017, the limit for individuals is $7,150 and the limit for families is $14,300, though your plan may have a limit that is lower
  • Keep in mind that only services covered by the plan count towards the maximum, and may only apply to care provided inside the plan’s network

Certain preventive services are often provided at no cost to qualifying patients under most plans, even if the plan has a deductible. These include immunizations and screenings for things like

  • Blood pressure
  • Cholesterol
  • Colorectal cancer
  • Depression
  • Diabetes
  • Alcohol and tobacco abuse
  • Obesity

View the full list of preventive services

Why might medicine cost so much?

Until you reach your deductible, you will have to pay the full cost of care for some services. Some prescription medicines may be covered with a copay or coinsurance before you reach your deductible on some plans, but you might pay the full cost on other plans.

If you don’t have health insurance, or have a plan that doesn’t cover prescription medicines, there are ways to lower your out-of-pocket costs. Since prescription medicines can have different prices at different pharmacies (including some that provide medicine by mail), comparing what you would pay at your local pharmacies might help you find a lower price.

Click here to use a tool that helps you compare costs at different pharmacies in your area. If you have insurance, check with your provider for your prescription costs.

Another way to lower drug costs may be to ask your doctor if a generic medicine (less expensive than brand name drugs) would be appropriate for you.

Some drug companies help patients with the costs of their medicines. These programs are subject to terms and conditions, and not all patients will be eligible for savings.

You may want to check if the drug company that makes your medicine offers a cost-savings program for which you are eligible. Because these programs can be discontinued or your eligibility can change, you should not rely on them when selecting health insurance coverage.

Savings offers on certain Merck medicines are available for eligible patients; please see the terms and conditions of the offer for eligibility requirements.

If you do not have prescription-drug coverage and cannot afford your medicines, you may be eligible for free Merck medicines through the Merck Patient Assistance Program Inc. Get the facts about this and other programs from Merck. Visit www.MerckHelps.com.

Employer/Private Insurer

Health Maintenance Organization

Consider if you/your family need health services regularly or are taking many prescription medicines

Exclusive Provider Organization Plan

Consider if you/your family need health services regularly or are taking many prescription medicines

Preferred Provider Organization

Consider if you/your family use a lot of health services or have many prescription medicines

Point of Service Plans

Consider if you/your family use a lot of health services or have many prescription medicines

High Deductible Health Plan

Consider if you/your family don't use health services often, or don't take many medicines routinely

What if I cannot afford a plan?

The government might help pay for your health insurance in the Marketplace in 1 of 3 ways, based on your income:

Why is it important to consider total cost of coverage, which includes premium as well as out-of-pocket costs?

It’s important to make sure you have the right amount of coverage at a cost you can afford.

Consider the following:

  • How many times did you and your family go to the doctor? How many prescription medicines are you taking? What did it cost you? These things give you an idea of how much health care might cost you in the future
  • If you have money readily available and are generally healthy, you may want to pay less each month at the risk of paying more for care if you need it
  • If you do not have access to larger amounts of money or may need lots of care, you might want to contribute more each month and pay less out of your own pocket each time you need care. For additional considerations, including information on ratings for different insurance plans, go to www.healthcare.gov

Other brands listed are the trademarks of their respective owners and are not trademarks of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.

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