What is a copay?
A copay, or copayment, is the amount paid out of pocket after a doctor's visit or when paying for prescription medicine. Copays may vary from one plan to another, and emergency room visits may cost more than routine doctor's visits.
Employees can view their plan's copay from the Medical Overview page under the Benefits Summary section.
When are copays commonly used?
Copays are commonly found as the benefit for more regular services, such as primary care doctor visits, specialist visits, and emergency coverage. Copays may also be used for In-Network services, but rarely for Out-of-Network services.
In most situations, the deductible does not need to be met before paying the copay (except if your plan is a High Deductible Health Plan). However, you should look at the plan Summary of Benefits and Coverage (SBC) to confirm that the deductible is waived for that service.
Example: Julia sees her primary care physician for a sinus infection. The visit to her doctor costs $250 before insurance, but under her insurance plan, primary care visits are a $20 copay with the deductible waived. Julia will only pay $20 at time of service.
Copay or Coinsurance?
Covered services will be subject to either a copay or coinsurance. Who provides the service (an in-network or out-of-network provider) also factors in. The plan's Summary of Benefits and Coverage will summarize what services are subject to a copay and which are subject to coinsurance, and when they would apply.
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