Copay alignment puts copays in line with the actual price of a health care service. Simply put, the higher the cost of the service, the higher the employee's copay. You can add copay alignment to nearly any health plan to reduce your group's premium costs while increasing your employees' awareness of the high cost of health care.
Copay alignment features
- Aligns copays with the actual cost of a service, for example:
- Can be added to any health plan, except HSA
- Available for small and large groups
- Five different copay structures to choose from
- No responsibility for you - this feature is simply added on to the health plan you pick
- Services requiring a copay aren’t subject to the deductible, so greater cost savings with larger deductibles are possible without changing incentives for accessing common services like visits to a doctor’s office, an urgent care center or an emergency room.
Contact the Priority Health employer representative for your region or your independent agent to get more information about how copay alignment will work for you.
Copay details
Primary care vs. specialist care copays
Under an HMO or POS plan, the primary care copay applies to visits to the member's designated primary care physician. Under a PPO plan, the primary care copay applies to visits to primary care physicians and other primary care providers, including:
- Family practice
- General practice
- Gynecology
- Internal medicine
- Obstetrics & gynecology (not all OB/Gyns are primary care physicians; see below)
- Pediatrics
- Internal medicine/pediatrics
Any other provider is considered a specialist.
Check the online Find a Doctor tool to find primary care physicians and other primary care providers by category.
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OB/Gyn care
- HMO or POS plans: If the OB/Gyn is the employee's primary care physician, the primary care copay applies. If he/she is not your PCP, the specialist copay applies (except for routine maternity care).
- PPO plans: A physician must be classified in the Priority Health system as a primary care physician to have the primary care copay apply. Not all OB/Gyns are classified as primary care providers. Check the online Find a Doctor tool and search for Primary Care to find OB/Gyns who are classified as primary care physicians.
- Routine maternity care: The primary care copay applies to all routine maternity services, with a maximum of four primary-care copays per pregnancy for routine prenatal and postnatal services.
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Urgent care copays
The urgent care copay applies to visits to all types of urgent care centers.
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Advanced diagnostic imaging copays
- Advanced diagnostic imaging tests include CT (CAT), MRI, MRA, advanced cardiac imaging and PET scans.
- This copay applies to tests done on an outpatient basis. Use of the ER is considered an outpatient visit.
- Employees will be charged a maximum of 10 such copays per individual per year. After that, the tests will be covered at 100%.
- There is no copay for these tests when the member is receiving inpatient hospital care. Any member coinsurance payment for the tests will apply to his/her deductible.
- If tests are performed under separate CPT codes (such as upper and lower back or chest and abdomen), the employee will be charged a separate copay for each test billed.
Note: Advanced diagnostic imaging done anywhere other than the ER requires prior authorization from the prescribing physician. If prior notification is not received, a $250 penalty applies.
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Last modified
12/12/09
