Creditable Coverage DIY Checker (Employer View)

Educational tool for plan design screening. Results are design-based and assume reasonable pharmacy access & coverage of brands/generics (including biologics). Employers remain responsible for notices and CMS disclosure.

72% Method — Plan Value Calculation

Show the plan is designed to pay ≥ 72% of covered Rx on average.

Total Plan-Paid Rx (12 mos or projection)

Total Member-Paid Rx (copays + coinsurance + Rx share of deductible)

Need help allocating an integrated deductible? (optional)

Total allowed charges: Rx

Total allowed charges: All (Rx + Medical)

Total member-paid deductible (all claims)

We’ll allocate deductible to Rx by share of allowed charges (Rx / All). Add this allocated amount to Member-Paid Rx above.

Awaiting input…

Notice Timing Helper

Is a plan change scheduled mid-year?

Effective date of change (if known)

Reality Check & Good Practices

Carriers/PBMs hold the needed data. Employers rarely have claim-level plan-paid vs. member-paid detail.
Same plan, same outcome: Determinations are design-based, so the carrier should be able to issue a blanket status per plan.
Test every option: Each plan offered needs its own determination & documentation.
Send notices: Annually by 10/15, at initial enrollment, upon request, and whenever creditable status changes (e.g., mid-year plan change).
Document: Save the carrier letter/actuarial memo, the calculations (if any), and proof of notices & CMS disclosure.
When in doubt: Escalate with the carrier or engage an actuary/TPA. Don’t guess.

This tool is for educational screening. Final compliance rests with the employer; rely on carrier/actuarial determinations where possible.

Creditable Coverage DIY Checker (Employer View)

72% Method — Plan Value Calculation

Notice Timing Helper

Existing Simplified Method (60%) — Design Screen

Optional quick ratio

Batch Calculator (Multiple Plans)

Reality Check & Good Practices