Medical Expense claim

I am trying to add a medical expense for one of the employee.
our medical expense claim policy is below.

if medical expense is less than 100,000 we pay 100% of the claim
if medical expense is greater than 100,000 we pay 50% of the claim
if medical expense is greater than 200,000 we pay 25% of the claim
if medical expense is greater than 300,000 we pay 0% of the claim

What i want is to put these limits in there so that when an employee is submitting their expense claim in ERP it automatically calculates the amount and shows it in the expenses table for the claim.

is there a way to do this. please help