What is a (Copayment) Copay in Health Medical Plans?

The copay is a flat payment that is the responsibility of you the patient that is assessed per event or visit. Each insurance company has different level of copays and your Doctor office staff will advise you at your time of the visitation what you’re out of pocket charges are for that visit. The medical office staff will submit the remainder of the bill to your insurance company as long as you are with an in network provider.

Some health medical plans also have separate copays for emergency room visits, lab testing, chiropractor visits and specialists. Read your health medical plans coverage of benefits booklet for more specifics on your plan prior to seeking medical attention. Your medical ID card issued by your insurance company also has your copays printed on them for ease of use and for the easy read for the Doctors office staff.

Copayment is the amount of money paid by you at the time of service for certain medical services and prescription drugs; these can range from $10 to $50 depending on your health medical plans. Copays do not apply to deductibles or out-of-pocket maximums. Health medical plans copays cover the office visit and preventive care when using in network providers and depend on whether the doctor is a general care physician or a specialist.

Example of how a copay might work in Health Medical Plans: You, the patient visit the doctor for a cold. You pay a $20 copay at the time of visit. The Doctor office bills the insurance company $100 for the negotiated price of the visit. Because the Doctor is contracted “in-network”, the insurance company only allows $100 to be charged for the office visit. Since $20 has already been paid by you the patient, they send a payment to the Doctor of the remaining balance due of $80.

If your health medical plans have a pharmacy (drug) card you may also have copays included with that benefit. These copays can have multiple tiers depending on the drug prescribed and how the insurance company has classified them. There is typically generic level; brand name (formulary) level and a brand name (non-formulary) level each at different copays.

To help save on your health medical plans premiums, you can adjust your copays higher or lower. The higher your copays the lower your insurance premium will be. It is best to see how you and your family utilize your health medical plans prior to making any changes to your plan design. Most families with young children find it beneficial to keep their copays low as they most often use them for children annual exams and often times many colds during the year. If your children are older and don’t visit the Doctors office regularly it may pay itself in savings to raise your copays to a higher level.