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What is a Copay?

Tricia Christensen
By
Updated Feb 05, 2024
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Even if you have medical insurance, it doesn’t necessarily mean that you get to visit a doctor, lab, or hospital, or purchase your prescription drugs for free. Instead most insurance companies require the insured to pay a portion of their total bill, at a set amount. In other types of insurance, like auto insurance, you have what is called a deductible, a set amount the insured person pays before the insurance company begins reimbursing the insured or others for damage of property or injury. Health insurance may employ either a copay or a deductible, or both.

In the past, before the advent of insurance care with network doctors and facilities, and primary care physicians, many health insurance companies operated on the 80/20 principle. When you went to a doctor’s office, you paid 20% of the bill, and either you or the doctor’s office billed the insurance company for the rest. This principle may still operate with certain types of insurance. For instance, people who have the ability to choose doctors out of network may pay 20%, or another percentage of the total instead of paying the flat fee they would for visits to network doctors. A network doctor is contracted with the insurance company to accept a set fee for services.

Since the 1970s, the shift in insurance trends has been for most people to be enrolled in a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), making the term copay very familiar. While some services may be offered without a copay or copayment, other services mean you will always have a set copay. For instance you might pay $15-25 US Dollars (USD) for a standard visit to a network or preferred provider doctor.

The statement that the copay is set at a certain amount needs to be further explored. Each service may have a different copayment, and some may not be covered at all. You might pay $100 USD for visiting an Emergency Room, $25 USD for a doctor’s visit, and $15 USD for prescriptions.

You may pay a higher copayment at the pharmacy if you specifically choose a name brand medication instead of a generic medication. Prices may change each year, as companies renegotiate with insurance companies. In early years when the copay was first introduced, amounts for a doctor’s visit were usually between $5-15 USD. Typically copayments are higher now, in the nature of $20-30 USD for a doctor’s visit. The trend in the insurance industry is to raise copayments without raising compensation for doctors; in other words, you pay more and the insurance company pays less to compensate medical professionals.

Deductibles need to be understood too, since it may be necessary for you to fulfill your deductible amount prior to beginning to make copayments for services. For instance you might have a $500 USD deductible on your plan. If you were hospitalized, you may have to pay that amount, rather than simply your copayment. If you have additional doctor’s visits or hospitalizations, once you’ve met your deductible, you will only pay the designated copay amount. Some services are exempt from meeting your deductible, like well-child visits and yearly gynecological exams. Other insurance companies offer a low deductible that is easily met with a few copays to a doctor.

WiseGeek is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Tricia Christensen
By Tricia Christensen
With a Literature degree from Sonoma State University and years of experience as a WiseGeek contributor, Tricia Christensen is based in Northern California and brings a wealth of knowledge and passion to her writing. Her wide-ranging interests include reading, writing, medicine, art, film, history, politics, ethics, and religion, all of which she incorporates into her informative articles. Tricia is currently working on her first novel.
Discussion Comments
By anon993786 — On Dec 14, 2015

If the patient is experiencing hard times, can the doctor opt to not charge the co-pay, or even share part of the insurance payment with the patient?

By spawn123 — On Oct 16, 2011

Why did I get charged a copay three times for the same injury? First by my doctor who then sent me to a specialist then the specialist sent me for an mri and then I went back and had a follow up on the mri. I got charged by my doctor then twice by the orthopedist once at the first visit, then again three days later at the follow up.

By anon78351 — On Apr 18, 2010

@anon18643: No, they are not.

Please read the article before commenting.

It says:

"Instead most insurance companies require the insured to pay a portion of their total bill, at a set amount. other types of insurance, like auto insurance, you have what is called a deductible, a set amount the insured person pays before the insurance company begins reimbursing the insured or others for damage of property or injury. Health insurance may employ either a copay or a deductible, or both."

By anon64788 — On Feb 09, 2010

Can an MD charge a copay for post op?

By anon18643 — On Sep 26, 2008

Are copay and deductible the same?

Tricia Christensen
Tricia Christensen
With a Literature degree from Sonoma State University and years of experience as a WiseGeek contributor, Tricia...
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