The annual deductible specified in your plan is the total coinsurance you must pay in a calendar year before the insurance company starts paying for any healthcare costs. This balance is called coinsurance.Ĭoinsurance may be higher when you see an out-of-network provider, but stays the same whether you see a GP or a specialist. The patient is responsible for the balance (10-40% of the allowed amount). If the deductible has been met, the insurance plan then covers a large percentage (usually 60-90%, depending upon the plan) of the allowed amount. If the provider is in-network, the insurance company first lowers the 'allowed amount' to the pre-negotiated rate for that service (more about this in the example below). The provider collects the copay from the patient at the time of service and bills the insurance company. The copay is usually too small to cover all of the provider's fees. High-deductible health plans (HDHP) usually do not have a copay.

When you see a provider 'in-network' - i.e., a provider that the insurance company has an agreement with - you may pay a lower copay than when you see a doctor out-of-network.Ĭopays are applicable until the annual out-of-pocket maximum is reached but many insurance plans waive copays for preventive care visits like annual physicals or child wellness checkups. Out-of-network: Insurance companies contract with healthcare providers to agree upon reimbursement rates.

This provides an incentive to lower costs by using drugs that are chemically equivalent but cheaper. brand name drugs: Copays for prescription drugs are around $5 to $20 per prescription, with lower copays for generics vs. General Physicians: Copays for specialist visits are usually higher than for general physicians. Copays are typically $15 to $50 per visit but may vary depending upon the following factors: A copay or copayment is the amount of money you are required to pay directly to the healthcare provider (doctor, hospital etc.) per visit, or to a pharmacy for every prescription filled.Ĭopays discourage unnecessary visits by making the patient responsible for a small portion of her healthcare costs.

Copay vs coinsurance