What Does Copay Mean in Health Insurance?

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A health insurance copayment, or copay, is a flat fee paid each time you visit the doctor, pick up a prescription or receive some other type of healthcare service. The copay amount can vary based on the service and your healthcare plan and in some cases, no copay will apply at all.

Learn how copays work and how they are different from coinsurance and deductibles.

Key Takeaways:

  • A copay is a flat fee paid each time you use a healthcare service, such as visiting a doctor, picking up prescription drugs or receiving urgent care.
  • For employer-sponsored health plans, the average copay for primary care is $26 and $44 for specialist care.
  • You will not need to pay a copay for certain preventive services if you’re enrolled in a marketplace health plan.
  • Copays will count toward your health insurance policy’s annual out-of-pocket limit and you will not need to pay copays once you reach the annual cap.

How Do Copayments Work?

Copays are one of the costs that a policyholder must pay out of pocket when receiving a health care. If you’ve ever visited the doctor and were charged a fee when checking in with the receptionist, you were likely paying your copay. Unlike coinsurance, which is percentage-based, copays are flat fees.

Copays will vary based on the type of medical service you receive and your health insurance plan. For example, a $25 copay may apply for an urgent care visit and a $10 copay for a generic drug prescription.

Common health care services that may require a copay include:

  • Doctor visits
  • Urgent care visits
  • Emergency room visits
  • Prescriptions
  • Laboratory tests
  • Hospital stays
  • Family practice
  • General practice
  • Specialist treatment (e.g., internal, gynecology, occupational therapy, speech therapy)

Is Copay Paid Out Of Pocket?

A copay is paid out of pocket, meaning your insurance company will not cover it for you when you receive a health care service. That said, copays are subject to out-of-pocket annual limits — the maximum you can pay in out-of-pocket expenses each year. Once you hit your maximum, your health insurance carrier pays for 100% of the medical costs. Copays, deductibles and coinsurance all count toward your annual limit.

For example, say you have a $8,000 annual out-of-pocket maximum. Over the plan year, you visit the doctor, undergo various medical examinations and receive treatment. Eventually, your deductible, copays and coinsurance total $8,000. Any subsequent out-of-pocket costs for covered services within your plan year are covered 100% by your insurance carrier.

What Is a Typical Copay?

Copays can differ based on the the service you’re receiving, with the average copay in employer-sponsored health plans being $26 for primary care, $44 for specialist services, $404 for hospital care and $217 for emergency room visits.[1] Below is an example of copays by service for a Silver plan purchased from Cigna.[2]



Health provider office or clinic


Prescription drugs

  • $10 for generic brands
  • $25 for preferred brands
  • $200 for non-preferred brands
  • $250 for specialty brands

Urgent care


Outpatient Services for mental health, behavioral health or substance abuse services


In addition, your copay amount can vary based on which category your policy falls under: bronze, silver, gold or platinum. For bronze plans, your copay and out of pocket costs are highest in exchange for paying the lowest monthly premium and for platinum plans, your out-of-pocket costs are lowest but your monthly premium the highest.[3]

What Happens If I Can’t Pay a Copayment?

Some facilities may refuse service if you cannot make your copayment and may reschedule your appointment to a date when can pay it.[4] The exception is for emergency services — a hospital must provide emergency medical care to anybody who needs it even if the patient cannot afford their copayment or is uninsured.[5]

If you’re a veteran with VA health care, it may be possible to set up a repayment plan to pay your copay bills over time or request a copay exemption if you’re experiencing financial hardship.[6]

When Aren’t Copayments Required?

Marketplace plans do not require you to pay a copayment for certain preventive services you receive within your plan’s network, even if you have not met your annual deductible. These services include:[7][8][9]

  • Alcohol misuse screening and counseling
  • Cholesterol screening
  • Depression screening
  • Type 2 diabetes screening
  • Diet counseling
  • Breastfeeding support
  • Birth control
  • Autism screening for children
  • Immunizations for children
  • Vision screening for children
  • Hearing screening for newborns

Click here for a comprehensive list of preventive services that do not require you to pay a copay.

Why Would I Still Need To Pay After a Copayment?

If you still owe a balance after making a copayment, it is likely that you have not met your deductible yet. Remember: your health insurance deductible is the amount you must pay over the policy year before your insurance company starts contributing toward your medical expenses.

Keep in mind that copays generally do not count toward your annual deductible.[10]

Can Copayments Be Refunded?

Copays may be refundable on a case-by-case basis or when new legislation requires it. For example, the American Rescue Plan (ARP), passed in March 2021, canceled copays charged to veterans for medical care and pharmacy services from April 6, 2020 to September 30, 2021. Veterans can claim refunds for copays paid during this period.[11]

In addition, if a facility collects a copay in excess of what you should have owed, then the difference should be refunded.[12]

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Do copays count as medical expenses?

Copays may meet the IRS definition of “medical expenses” and may qualify as a tax-deductible expense.[13] Be sure to consult an accountant or tax specialist to ensure you are meeting your federal and state tax obligations.

Can a copay be waived?

Some medical providers have waived copays but it is generally discouraged and may even be illegal since it violates the cost-sharing aspect of health insurance — a copay is one of the ways a policyholder pays their share of the cost of healthcare services.[14]

Are copays tax deductible?

Copays may be tax deductible but only among the expenses that exceed 7.5% of your adjusted gross income.[13] Consult your tax advisor to ensure you are in full compliance with your state and federal tax laws.

Is it better to have a copay or deductible?

Copays and deductibles are two different things that are included in many health insurance policies so it’s not about picking one over the other. A deductible is what you must pay out of pocket before your insurance kicks in, while a copay is a fee you pay each time you receive a certain healthcare service.

Does the doctor keep the copay?

Yes. In general, the doctor or facility charging the copay keeps the payment.


  1. Kaiser Family Foundation. “2023 Employer Health Benefits Survey.” Accessed Jan. 30, 2024.
  2. Cigna. “Summary of Benefits & Coverage,” Pages 2-4. Accessed Jan. 30, 2024.
  3. Healthcare.gov. “The Health Plan Categories: Bronze, Silver, Gold & Platinum.” Accessed Jan. 30, 2024.
  4. John Hopkins Medicine. “Appointment Information.” Accessed Jan. 30, 2024.
  5. National Highway Traffic Safety Administration. “Emergency Medical Treatment and Labor Act.” Accessed Jan. 30, 2024.
  6. U.S. Dept. of Veteran Affairs. “Request VA Financial Hardship Assistance.” Accessed Jan. 30, 2024.
  7. Healthcare.gov. “Preventive Care Benefits for Adults.” Accessed Jan. 30, 2024.
  8. Healthcare.gov. “Preventive Care Benefits for Women.” Accessed Jan. 30, 2024.
  9. Healthcare.gov. “Preventive Care Benefits for Children.” Accessed Jan. 30, 2024.
  10. UnitedHealthcare. “Copay, Coinsurance and Out-of-Pocket Maximum.” Accessed Jan. 30, 2024.
  11. U.S. Dept. of Veteran Affairs. “Copayment Refund Notification Letters Mailed to Veterans.” Accessed Jan. 30, 2024.
  12. The Journal of Urgent Care Medicine. “Refunds: How To Avoid Them.” Accessed Jan. 30, 2024.
  13. Internal Revenue Service. “Medical and Dental Expenses for Use in Preparing 2023 Returns,” Pages 2-3. Accessed Jan. 30, 2024.
  14. Maryland Local Health Department. “Office of Inspector General: Waiving Co-pays or Co-insurance.” Accessed Jan. 30, 2024.

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