---
title: "What Is a Copay? Meaning and Example | Riskado"
description: "A copay is a fixed dollar amount you pay for a covered health-care service. See a $20 worked example, common amounts by service, and what to ask your insurer."
url: "https://riskado.com/insurance-terms/copay/"
lang: "en"
published: "2026-08-16"
modified: "2026-10-01"
image: "https://riskado.com/og/default.jpg"
alternates:
  es: "https://riskado.com/es/terminos-de-seguros/copago.md"
---

# Copay

[Life and Health](https://riskado.com/life-and-health-insurance/) · Updated Oct 1, 2026

A copay, or copayment, is a fixed dollar amount you pay for a covered health-care service, usually when you receive care. The amount can differ by service, provider network, or prescription tier. Your deductible may apply first, and the plan pays the remaining covered amount under its terms.

Also called: copayment, copayments

Your copay is the dollar figure printed next to a service on your [health plan](https://riskado.com/insurance-terms/health-insurance/), such as a doctor visit or a prescription. It stays the same whatever the provider bills for that service. Some plans ask for it right away, and others make you pay the full allowed amount until the [deductible](https://riskado.com/insurance-terms/deductible/) is met.

## How a copay works, with real numbers

On a $100 allowed amount for a doctor's office visit with a $20 copay, a member whose deductible has been met pays $20 and the plan pays $80, which is $100 minus $20, according to [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/co-payment/). If the deductible has not been met, the member pays the full $100 allowed amount instead of the $20 copay, subject to the plan's terms. These figures are an official illustration, not an average.

A $100 allowed amount for a doctor visit with a $20 copay

Hover or tap a row to highlight it.

| Situation | You pay |
| --- | --- |
| Deductible already met | $20 copay (the plan pays $80) |
| Deductible not yet met | $100, the full allowed amount |

[Coinsurance](https://riskado.com/insurance-terms/coinsurance/) works differently. It is a percentage of the allowed amount, such as 20%, which comes to $20 on a $100 service, according to [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/co-insurance/). A copay stays a stated dollar amount whether the allowed charge is $50 or $500, subject to plan conditions, so a larger bill does not raise it.

## Common copay amounts and what changes them

Copay amounts vary by plan and service. These are examples, not national averages.

Copay examples for common services

Hover or tap a row to highlight it.

| Service | Example copay | Where the example comes from |
| --- | --- | --- |
| Doctor visit | $20 | [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/co-payment/) |
| Specialist | $45 | [Connecticut Office of the Healthcare Advocate (opens in a new tab)](https://portal.ct.gov/oha/knowledge-base/articles/health-insurance/resources/insurance-costs-terminology-to-know) |
| Primary care | $25 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Specialist | $40 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Urgent care | $60 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Emergency room | $150 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Prescription, Tier 1 | $10 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Prescription, Tier 2 | $35 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Prescription, Tier 3 | $70 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Physical, occupational or speech therapy | $30 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |
| Diagnostic laboratory or imaging | $40 | [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny) |

The amount you see also depends on how the plan is built. Plans can set separate in-network and out-of-network copays, prescription tiers, and per-visit or per-admission charges, before or after the deductible. Lower [premiums](https://riskado.com/insurance-terms/premium/) generally go with higher copays, and higher premiums with lower copays, according to [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/co-payment/).

## Where you will see the term

Copay is mainly a health-insurance word. It shows up in individual and employer-sponsored plans, Medicare, Medicaid, CHIP, dental, vision, prescription-drug [coverage](https://riskado.com/insurance-terms/coverage/), and HMO, PPO, EPO and POS plans. On paper, it appears in a quote or plan comparison, the [Summary of Benefits and Coverage (opens in a new tab)](https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/), the [policy](https://riskado.com/insurance-terms/policy/), certificate or Evidence of Coverage, the member ID card, a renewal notice, an Explanation of Benefits, and the provider's bill.

Ordinary auto, homeowners, renters, condo, life and commercial property policies do not use a copay. They use deductibles, limits, exclusions, coinsurance or percentage participation instead. A pet policy may use the word in its own way, and that contract controls.

## Connecticut and New York rules that change a copay

Connecticut sets limits on some copays. Under [Conn. Gen. Stat. § 38a-511a (opens in a new tab)](https://www.cga.ct.gov/current/PUB/chap_700c.htm#Sec38a-511a), an individual health policy may not charge more than $30 per visit for in-network physical therapy or occupational therapy by the specified licensed professionals, and copayment-only health plans as defined in § 38a-511(c) are excluded. Group policies fall under [Conn. Gen. Stat. § 38a-550a (opens in a new tab)](https://www.cga.ct.gov/current/PUB/chap_700c.htm#Sec38a-550a).

[Connecticut Insurance Department Bulletin HC-109 (opens in a new tab)](https://portal.ct.gov/cid/-/media/cid/hc109maximumcostsharingpdf.pdf), issued February 5, 2016, lists maximum copays for policies issued or renewed on or after January 1, 2017: $25 for durable medical equipment, $225 for ambulance services, $10 for laboratory services and $40 for routine radiology. Qualifying third-party discounts or payments must be credited when an insured's copayment or other out-of-pocket expense is calculated, under [Conn. Gen. Stat. § 38a-477aa (opens in a new tab)](https://www.cga.ct.gov/current/PUB/chap_700c.htm#Sec38a-477aa).

In New York, [Insurance Law § 3217-a (opens in a new tab)](https://www.nysenate.gov/legislation/laws/ISC/3217-A) requires insurers subject to it to give insureds and prospective insureds written disclosure of their financial responsibility for premiums, coinsurance, copayments, deductibles, caps on covered-service payments and noncovered services. [Insurance Law § 4306-h (opens in a new tab)](https://www.nysenate.gov/legislation/laws/ISC/4306-H) defines cost sharing to include copayments and limits cost sharing for essential health benefits in qualifying plans. For emergency care, covered people are generally responsible only for in-network cost sharing, including the in-network copayment, even when a hospital is out of network, according to the [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/health_insurance/rights_responsibilities).

## Questions to ask your agent or insurer

1.  What is my copay for each service I expect to use, including primary care, specialists, urgent care, emergency care, therapy, hospital care and prescriptions? Copays can vary by service and by prescription tier.
2.  Does the deductible apply before this copay, or does the copay apply right away? When the plan applies the deductible first, you can owe the full allowed amount until it is met.
3.  What are the in-network and out-of-network copays, and does the plan cover out-of-network care at all? Out-of-network benefits may carry higher cost sharing or may not exist, and balance billing can add to what you owe.
4.  Which copays count toward the out-of-pocket maximum? The plan's cost-sharing rules decide whether copays reduce the remaining annual limit.
5.  Does the copay depend on prior authorization, a referral or a network provider? A service can list a copay and still carry conditions on coverage, referral, network or medical necessity.

## Frequently asked questions

These questions come up once the amounts are clear.

### Does a copay count toward my out-of-pocket maximum?

Often, copays for covered in-network services count, but the plan document controls. Premiums, noncovered services and many balance-billed amounts generally do not count, according to [HealthCare.gov (opens in a new tab)](https://www.healthcare.gov/glossary/cost-sharing/).

### Do I always pay the listed copay?

No. The service has to be covered and the plan's conditions have to be met. The deductible, network, authorization, referral and benefit rules can all change the amount owed; noncovered care and amounts above the allowed amount can stay with the member.

### Can an emergency-room visit have a copay?

Yes. A plan can list a separate emergency-room copay. New York's Healthy NY 2026 example lists $150 for an emergency-room visit, waived if the patient is admitted, according to the [New York Department of Financial Services (opens in a new tab)](https://www.dfs.ny.gov/consumers/healthyny).

### Does a preventive visit have a copay?

Recommended preventive services generally have no cost sharing when the federal requirements apply and the service is in network. Nevada's Division of Insurance says covered in-network preventive services must be available without copays, deductibles or coinsurance when the preventive-care rules apply, per its [healthcare reform page (opens in a new tab)](https://doi.nv.gov/Healthcare-Reform/Individuals-Families/).

## Related terms