Copays are determined by your health plan. For certain services, such as doctor visits and prescription medications, a copay is a set dollar amount you pay each time you use that service. This is your portion of the cost of the service.

Here’s a fictional example of how it could work, depending on the plan:

Bob visits his in-network primary care provider (PCP). The full cost of the visit is $100, but Bob’s marketplace health insurance plan indicates that he has a $40 copay for PCP visits. Bob will pay $40 to his PCP at the time of his visit. Bob’s health plan will pay the remaining $60. Bob’s care provider will bill his insurer directly.

Copays are separate from deductibles, so Bob will continue to pay his $40 copay each time he visits his in-network PCP, both before and after he meets his deductible. Copays may only end once Bob has met his out-of-pocket maximum.

Depending on your health plan, you may have a copay, a deductible or both.

• A copay is a fixed dollar amount that you pay for certain in-network services.
• Except on services that have copays, a deductible is the amount you pay for in-network healthcare before your health insurance begins to pay for covered services.

If your plan requires that you pay a copay from the start, the money you spend on copays usually will not go toward your deductible.

Yes, a copay is an out-of-pocket cost. Depending on the plan, your copay will usually count toward your out-of-pocket maximum. Once you reach your out-of-pocket maximum, your health plan will pay 100% of your costs.

Copays are usually paid at the time of service or when you pick up medications at the pharmacy.

Yes. If you have to pay copays for certain services, the copays will be required until you meet your out-of-pocket maximum.

If you are charged more than your copay, it could be because you received a service that was not covered by the copay. For example, if your plan requires you to pay a $40 copay when you visit the doctor, but you get an x-ray while at the doctor, the x-ray is covered differently. The amount you have to pay for the x-ray will depend on other details of your plan.

Before you choose a healthcare plan, check the plan details to understand copays and other payments that may apply.

On each in-network service covered by copayments, you pay the copay, and your plan pays the rest. Other costs, such as deductible and coinsurance, may also apply, depending on the services provided.

Health plans are required to cover most preventive services, such as vaccinations and screening tests, at no cost to you. So when you visit an in-network provider for these fully covered services, you will not have to pay a copay.

Copay amounts vary by plan and type of service. Copays for specialists, such as dermatologists, are usually more than copays for visits with your PCP. You may find copays as low as $10, but plans with such low copays are likely to have higher monthly premiums. When you’re shopping for plans, you can usually find copay information in each plan’s “plan details” section.

When you shop for health insurance, you can opt to see if you qualify for savings, called subsidies. If you qualify for a cost-sharing reduction subsidy, you may be able to get lower copays, but you will have to enroll in a “silver” level plan. If you are eligible and enroll in a silver plan, you will automatically have the version of the plan with reduced cost-sharing charges, which includes reduced copays.