A copay (short for copayment) makes healthcare costs predictable. Instead of wondering what you'll owe, you know the exact amount before you walk in the door. Whether your doctor visit costs $150 or $300, your copay stays the same.
How Copays Work
Copays are straightforward:
- You schedule a doctor visit or pick up a prescription
- At checkout, you pay your fixed copay amount
- Your insurance handles the rest of the bill
- The copay is the same every time for that service type
David's plan has a $30 copay for primary care visits. He sees his doctor for a cold. The visit is billed at $175. David pays $30 at the front desk. His insurance pays the remaining $145. Next month, he returns for a follow-up. Even though this visit is billed at $200, David still only pays $30.
Common Copay Amounts
Copays vary by plan and service type. Here are typical ranges:
| Service Type | Typical Copay Range |
|---|---|
| Primary care visit | $20 - $40 |
| Specialist visit | $40 - $75 |
| Urgent care | $50 - $100 |
| Emergency room | $150 - $500 |
| Generic prescription | $5 - $20 |
| Brand-name prescription | $30 - $60 |
| Specialty prescription | $100 - $300+ |
When Copays Apply
Copays typically apply to specific services, often before or regardless of your deductible:
Services That Usually Have Copays:
- Doctor office visits (primary care and specialists)
- Prescription medications
- Urgent care visits
- Emergency room visits
- Mental health visits
- Physical therapy sessions
Services That Usually Don't Have Copays:
- Preventive care (annual checkups, vaccinations)
- Hospital stays (usually coinsurance instead)
- Surgery (usually coinsurance after deductible)
- Lab work and imaging (varies by plan)
Always check if your visit is coded as "preventive" or "diagnostic." A preventive annual exam is usually free, but if you mention a specific health concern, part of the visit may be coded as diagnostic with a copay. Ask your doctor's office how they'll bill it.
Copays and Your Deductible
One of the most confusing aspects of insurance: how copays interact with deductibles.
In Most Plans:
- Copays apply before you meet your deductible
- Copays usually don't count toward your deductible
- Copays do count toward your out-of-pocket maximum
This means you can see a doctor and pay just your copay even if you haven't met your deductible. However, not all services work this way. Hospital stays and surgeries usually require meeting your deductible first.
Copay vs. Coinsurance
These two terms are often confused:
- Copay: Fixed dollar amount ($30) - stays the same regardless of cost
- Coinsurance: Percentage of cost (20%) - varies based on the total bill
See our detailed Copay vs. Coinsurance comparison for more examples.
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Get Free GuidanceFrequently Asked Questions
Do I always have to pay a copay?
Not always. Preventive services (annual checkups, screenings, vaccinations) are usually covered at 100% with no copay under ACA-compliant plans. Also, once you reach your out-of-pocket maximum, you won't owe copays for the rest of the year.
Why is my specialist copay higher than my primary care copay?
Insurance plans tier their copays based on service type. Specialists have more training and typically charge more, so plans set higher copays. This also encourages you to see your primary care doctor first, who may be able to address your concern without a specialist.
Do copays count toward my out-of-pocket maximum?
Yes. All copays you pay for covered services count toward your out-of-pocket maximum. Once you reach this limit, your insurance pays 100% of covered care for the rest of the plan year.
What if I can't afford my copay?
Many providers offer payment plans or sliding-scale fees for patients who struggle to pay. Some pharmaceutical manufacturers offer copay assistance programs for expensive medications. Your agent can also help you find a plan with lower copays during the next enrollment period.