What is a copay and when does it come into play?

A copay, short for copayment, is a fixed amount of money that individuals are required to pay
out-of-pocket for certain services or prescriptions. A copay is a form of cost-sharing between
the patient and their insurance provider. The amount varies depending on the specific services,
such as doctor visits, specialist consultations, medications, or medical procedures.

When do copayments come into play?

1. Doctor’s visits – The amount varies depending on the insurance plan itself, location of appointment (urgent care vs regular appointment) and the type of provider. Examples: Primary Care Physician vs Specialist.
2. Prescription Medications – Copays can differ based on the type of medication and where they fall on a formulary.
3. Emergency Room – copayments are generally higher than those for regular doctor visits, due to the urgency and specific services provided.
4. Hospitalizations & Procedures – Depending on the insurance plan, copayments may be required for hospital stays, surgeries, or other medical procedures.

Terminology

• Out-of-pocket maximum – The most an individual will spend out of their own pocket in one policy period (12 months). Does not include premium($).
• Cost-sharing – Individuals sharing cost with their insurance provider. Copays are an example of cost sharing.
• Insurance Provider – Insurance carrier or company, like BlueCross BlueShield or UnitedHealthcare.
• Primary Care Provider (PCP) – Health care professional who is responsible for monitoring an individual’s health care needs. PCP is a general doctor who is typically a ‘gatekeeper’ referring individuals to specialists for certain needs.
• Specialists – A doctor who focuses in a certain field, like cardio, orthopedic, gastroenterology, etc.
• Formulary – A list of drugs created by the pharmacy benefit manager that are already approved for coverage under an individual health plan.