Copay
A copay (or co-payment) is a fixed amount you pay each time you use a covered health service — for example, £20 per GP visit or $30 per specialist visit. The insurer pays the remainder. Copays are distinct from deductibles and coinsurance.
How copays work in practice
When you visit a healthcare provider under a copay plan, you pay the fixed copay amount directly to the provider at the time of service — regardless of the total billed cost. The insurer pays the remaining allowed amount directly to the provider.
Common copay structures in US health insurance:
Typically the lowest copay tier — often $20–$40 per visit. Some plans offer preventive care at $0 copay under ACA rules.
Higher than primary care — commonly $40–$80 per visit. In-network specialists are significantly cheaper than out-of-network.
The highest copay tier — often $250–$500 per visit. This fee is frequently waived if you are admitted as an inpatient.
Tiered by formulary level: generic drugs have the lowest copay (e.g. $10), brand drugs are higher, specialty drugs highest (sometimes coinsurance instead of a flat copay).
Copay vs deductible vs coinsurance
These three cost-sharing mechanisms work differently and often operate simultaneously within a single health plan:
- Copay — fixed amount per service, applies regardless of whether the deductible has been met (on many plans)
- Deductible — the amount you pay first before the insurer starts sharing costs on most covered services
- Coinsurance — your percentage share of costs after the deductible has been met
Our guide to coinsurance and copays explains how all three interact when calculating what you owe for a specific service, and how the out-of-pocket maximum caps your total annual exposure.
Copay FAQ
Frequently asked questions
- It depends on the plan. In some US health plans, copays count toward the annual deductible; in others they do not. Some plans waive copays entirely until the deductible is met; others apply copays from the first visit regardless. Check your Summary of Benefits and Coverage (SBC) document or your deductible section in the policy. The HealthCare.gov glossary provides the standard US definition.
- A copay is a fixed flat amount (e.g. $25 per visit) regardless of the total cost of the service. Coinsurance is a percentage you owe after the deductible is met (e.g. you pay 20% of the allowed amount, the insurer pays 80%). Copays are predictable; coinsurance varies with the cost of the service. Many US plans use both — a copay for primary care and coinsurance for hospital stays.
- Copay structures are most common in US health insurance. In the UK, NHS care is free at the point of use, but private medical insurance (PMI) policies may include an excess or co-payment element. In Australia, Medicare covers most GP visits at no cost, but private health insurance policies use excess and gap payment structures rather than a US-style copay. The terminology varies: in the UK the equivalent concept is often called a patient charge or policy excess.
- Under the US Affordable Care Act (ACA), all cost-sharing — including copays — counts toward the out-of-pocket maximum for ACA-compliant plans. Once you reach the out-of-pocket maximum, the insurer pays 100% of covered services for the rest of the plan year. For non-ACA-compliant or grandfathered plans, check your policy documents, as copays may or may not count.