A copay is a fixed dollar amount you pay out of your own pocket when you use a covered medical service

Your insurance company sets the copay amount—often $20, $30, or $50 depending on the type of visit—and you pay it at the time of service. The insurance company then pays the rest of the bill to the provider. A copay is separate from your deductible, your coinsurance, and your monthly premium. You can owe a copay even if you haven't met your deductible yet.

Copays exist because insurance companies use them to discourage unnecessary visits while keeping premiums lower for everyone. They are predictable: you know exactly what you'll pay before you walk into the office. That predictability is the main difference between a copay and coinsurance, where you pay a percentage of the bill instead of a flat amount.

Key Takeaways

  • A copay is a fixed dollar amount you pay at the time of service, separate from your deductible and coinsurance.
  • Different services carry different copay amounts—a primary care visit might be $25, but a specialist visit might be $50 or more.
  • You pay the copay directly to the provider's office, usually at check-in or checkout.
  • Copays do not count toward your deductible, but they may count toward your out-of-pocket maximum depending on your plan.

How copays differ from deductibles and coinsurance

A deductible is the amount you must pay out of your own pocket before your insurance starts paying anything at all. Once you meet your deductible, your insurance kicks in. A copay, by contrast, is what you pay every single time you use a service, even after your deductible is met. If your deductible is $1,500 and you've already paid $1,500 this year, you still owe your copay at the next doctor's visit.

Coinsurance is a percentage of the bill you pay after your deductible is met. If your coinsurance is 20 percent and a lab test costs $100, you pay $20 and insurance pays $80. A copay is simpler: you pay the same amount every time, regardless of what the actual bill is. Some plans use copays for routine visits and coinsurance for other services, or they use coinsurance only after you've paid a certain number of copays.

What types of visits have copays

Most insurance plans charge copays for primary care doctor visits, specialist visits, urgent care, and emergency room visits. The amounts vary: a visit to your regular doctor might be $20 or $25, while a visit to a cardiologist or dermatologist might be $40 or $60. Emergency room copays are usually higher—$150 to $300—because they discourage people from using the ER for non-emergencies.

Prescription drugs often have copays too, usually tiered by how expensive the medication is. A generic drug might have a $10 copay, a brand-name drug on the formulary might be $30, and a brand-name drug not on the formulary might be $50 or more. Mental health visits, physical therapy, and imaging like X-rays or MRI scans may also have copays, though some plans waive copays for preventive services like annual checkups or cancer screenings.

Hospital stays and surgeries typically do not have copays. Instead, you pay your deductible and then coinsurance for the portion of the bill your insurance doesn't cover. Some plans waive copays for certain preventive services—like flu shots or colonoscopies—to encourage people to get them.

When you pay the copay and to whom

You pay your copay at the time you receive the service, not later. At a doctor's office, you usually pay at check-in or at checkout, depending on the office's system. At a pharmacy, you pay the copay when you pick up your prescription. At an urgent care or emergency room, you may pay at registration or after you've been seen.

You pay the copay directly to the provider—the doctor's office, hospital, pharmacy, or clinic. The provider keeps the copay and bills your insurance company for the rest. If you don't pay the copay, the provider may refuse to see you or may send your bill to collections. Some providers offer payment plans if you can't pay the full copay at the time of service, but this is not may provide.

How copays count toward your out-of-pocket maximum

Your out-of-pocket maximum is the most you will pay in a year for covered services. Once you reach it, your insurance pays 100 percent of covered services for the rest of the year. Copays count toward this maximum on most plans, though the rules vary by insurance company and plan type.

If your out-of-pocket maximum is $5,000 and you've paid $4,800 in copays and coinsurance so far this year, your next $200 in medical costs will be covered by you, and then your insurance will cover everything else for the rest of the year. However, your monthly premium does not count toward the out-of-pocket maximum, and neither do any bills for services your insurance doesn't cover.

What happens if you can't pay your copay

If you cannot pay your copay at the time of service, tell the provider's office before or immediately after your visit. Some offices will let you pay later or set up a payment plan. Others may refuse to see you or may send an unpaid copay to a collection agency, which will damage your credit score.

If a copay is sent to collections, you can try to negotiate a settlement with the collection agency or the provider's office. You can also dispute the debt if you believe it is incorrect. Paying the debt will not remove it from your credit report immediately, but it will show as "paid" rather than "unpaid," which is better for your credit score. If you are struggling to pay copays regularly, look into whether you may have access to for Medicaid or a low-income insurance plan through your state's marketplace.

Copays on insurance plans you choose

When you shop for health insurance—through your employer, the ACA marketplace, or a private insurer—you can compare copay amounts across different plans. Plans with lower monthly premiums often have higher copays, while plans with higher premiums often have lower copays. There is no "best" choice; it depends on how often you expect to use medical services.

If you see a doctor frequently or take multiple medications, a plan with lower copays and a higher premium might save you money overall. If you are young and healthy and rarely see a doctor, a plan with higher copays and a lower premium might be cheaper. When you enroll in a plan, you will receive a document called the Summary of Benefits and Coverage (SBC), which lists all copay amounts for different services. Read this document carefully before you enroll.

Frequently Asked Questions

Does my copay count toward my deductible?

No. Your copay and your deductible are separate. You pay your copay every time you use a service, and you also pay toward your deductible until you reach it. Once your deductible is met, you still owe your copay at each visit. However, copays do count toward your out-of-pocket maximum.

What if my doctor is out of network?

If you see an out-of-network doctor, your copay may not apply. Instead, you may owe your full deductible and then coinsurance. Out-of-network care is usually much more expensive. Always check whether your doctor is in-network before you schedule a visit, or ask the office to verify your coverage.

Do I have to pay a copay for a telehealth visit?

Most plans charge the same copay for a telehealth visit as they do for an in-person visit with the same type of provider. Some plans waive copays for telehealth to encourage people to use it. Check your plan documents or call your insurance company to confirm what your copay is for telehealth.

Can a provider charge me more than my copay?

No, not if the provider is in-network. You pay your copay, and the provider bills your insurance for the rest. If the provider is out-of-network, you may owe more than the copay. If a provider charges you more than your copay for an in-network visit, contact your insurance company to dispute the charge.

What if I lose my insurance card before my visit?

Call your insurance company or log into your online account to get your member ID number. You can give this number to the provider's office instead of showing your card. The office will look up your copay amount in their system. Bring your ID when you arrive so the office can verify your information.