Copay (Copayment)
A copay is a fixed dollar amount that an insured person pays for a covered healthcare service, typically due at the time of service, regardless of the total cost.
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Exam Tip
Copay = fixed amount ($25). Coinsurance = percentage (20%). Know the difference!
What is a Copay?
A copayment (copay) is a fixed amount you pay for a covered health care service when you receive it. Unlike coinsurance (a percentage), copays are a set dollar amount.
Common Copay Amounts
| Service | Typical Copay |
|---|---|
| Primary care visit | $20-$40 |
| Specialist visit | $40-$75 |
| Urgent care | $50-$100 |
| Emergency room | $150-$500 |
| Generic prescription | $10-$20 |
| Brand prescription | $30-$60 |
| Specialty prescription | $100+ |
How Copays Work
- You visit the doctor
- You pay the copay at time of service
- Insurance covers the rest (for covered services)
- No waiting to meet deductible (usually)
Copay vs. Coinsurance
| Feature | Copay | Coinsurance |
|---|---|---|
| Amount | Fixed ($25) | Percentage (20%) |
| Predictability | Very predictable | Varies with cost |
| Deductible | Often before deductible | After deductible |
| Best for | Routine care | Major medical |
Copays and Deductibles
Some plans require copays before the deductible is met. Others apply copays only after the deductible. Read your plan carefully.
Copay Accumulators
Some plans have "copay accumulator" programs where manufacturer coupons don't count toward your out-of-pocket maximum or deductible.
No Copay Services
Under the ACA, many preventive services have no copay:
- Annual wellness visits
- Certain screenings (mammograms, colonoscopies)
- Immunizations
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Coinsurance (Health Insurance)
Coinsurance is a cost-sharing arrangement where the insured pays a percentage of covered medical expenses after the deductible is met, typically 20% with insurance paying 80%.
Deductible (Health Insurance)
A deductible is the amount a policyholder must pay out-of-pocket before the insurance company begins to pay for covered expenses.
Out-of-Pocket Maximum
The out-of-pocket maximum is the most you have to pay for covered healthcare services in a plan year, after which your insurance pays 100% of covered costs.
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