When you get medical services, you may be asked to pay a fee at the clinic or pharmacy. This is called a copay, and it’s one of the ways you share the cost of medical expenses with your health coverage.
What is a copay? A quick definition
A copay is a fixed price that you pay for some medical care, like doctor visits or prescriptions. Unlike coinsurance (which is a percentage of the total cost of care), your copay doesn’t change based on the cost of the services you receive.
Copays are common for routine care (such as primary care visits, some specialist appointments and prescription medications). You may have different copay amounts for the type of prescriptions you get or the type of doctor you see.
On some plans, copays apply regardless of whether you've met your deductible. On others, you are responsible for the full cost of care until you have met your deductible. You can find the details of your copay amounts for different services and prescriptions in your member portal account.
How copays work for visits, specialists and prescriptions
When you visit a primary care provider or specialist, their office typically checks your coverage information to collect the right amount for your copay. You may be asked to pay when you check in for your appointment, or you may be billed after your provider submits a claim to your plan. If you’ve met your deductible or the service is copay-only before deductible, the plan pays the rest of the visit cost for in-network care.
Copays apply to many types of care, but your deductible or coinsurance may apply to others. If your doctor orders bloodwork, imaging or other services outside of your plan’s copay agreement, you may have additional costs beyond the office copay. If you have not reached your deductible , you must pay the full amount for the additional services. If you have reached your deductible, you only pay the coinsurance amount — a percentage of the total cost.
Copays can apply to prescriptions, too. Many health plans group prescriptions into tiers based on their total cost, and each tier has its own copay. For example, a low-cost or generic drug might have a copay of only $5, while a brand-name drug could have a copay of $50 or more. Just like with medical care, your plan covers the rest of the cost of the medication once you’ve paid the copay.
Copay vs. deductible vs. coinsurance: How they differ
Most health coverage uses three cost-sharing tools for medical services. Understanding how they work and how they differ can help you know what you might owe for upcoming medical care.
- A copay is a flat fee that you pay for certain covered services. It doesn’t change based on the price of the service. For example, you may have a specialist copay of $40. Whether the specialist visit costs $500 or $1000, your copay would still be $40.
- A deductible is the total amount you must pay out of pocket for care before your plan starts sharing costs. For example, if your deductible is $2,000, you must pay any bills in full up to that amount before the plan starts paying for services.
- Coinsurance is the percentage you pay for health services after reaching your deductible; your plan provider pays the rest. For example, if your coinsurance is 20% and you’re charged $1,000 for care, you pay $200 and your plan pays $800.
Do copays count toward your deductible or out-of-pocket maximum?
Typically, copays do not count toward your deductible. And even if you have reached your deductible for the year, you will still be required to pay a copay for services that qualify for a copay on your health plan. That’s because copays and deductibles serve separate purposes. Your deductible is meant to cover significant medical expenses, while your copay provides affordable cost sharing for routine medical care from day one.
However, a copay does count toward your out-of-pocket maximum. Once you’ve reached your out-of-pocket maximum, you are no longer responsible for copays until the plan year ends and your out-of-pocket maximum resets.
Typical copay amounts and what affects them
There is no set copay amount—it varies by plan, and even by service. Factors that can affect copays include:
- Service or facility type: You might have a different copay for primary care, specialty care, urgent care and an emergency room visit.
- Your plan: Even with the same health coverage provider, copays can vary among the different plans available.
- Provider network: Your copay may be lower for in-network providers and higher for out-of-network providers.