Glossary
Copay
A fixed dollar amount you pay for a covered health service at the time you receive care, such as $30 for a primary care visit.
Last updated: May 11, 2026
A copay (also called a copayment) is a fixed dollar amount you pay for a covered health service at the time you receive care.
A typical Silver plan copay might be $30 for a primary care visit, $60 for a specialist visit, or $15 for a generic prescription. You pay the copay regardless of the underlying cost of the service — the rest is the insurer’s problem.
Examples
- Primary care visit copay: $30 → you pay $30 at check-in, the plan covers the rest.
- Specialist visit copay: $60 → you pay $60, the plan covers the rest.
- Generic prescription copay: $10 → you pay $10 at the pharmacy, the plan covers the rest.
- Emergency room copay: $250 → you pay $250 if admitted, the plan covers the rest (some ER copays are waived if you are admitted).
Copays vs. coinsurance
- Copay = fixed dollar amount ($30 per visit, $15 per prescription).
- Coinsurance = percentage (20% of the cost, for example).
Many Marketplace plans use copays for routine care (primary care, specialist visits, prescriptions) and coinsurance for big-ticket items (surgery, hospital stays, advanced imaging).
Copays before or after the deductible
Some plans charge copays before the deductible for primary care and generic drugs — meaning you do not have to meet a deductible first. Other plans require you to hit the deductible before copays kick in. Always check the plan’s Summary of Benefits.
Copays count toward your out-of-pocket maximum
Every copay you pay during the year counts toward your out-of-pocket maximum. Once you hit that ceiling, the plan pays 100% of covered services for the rest of the year — no more copays.
Copays by metal tier (typical for 2026)
| Tier | Primary care | Specialist | Generic Rx |
|---|---|---|---|
| Bronze | $40-$70 | $80-$150 | $15-$30 |
| Silver | $20-$50 | $50-$100 | $10-$25 |
| Gold | $10-$30 | $30-$60 | $5-$15 |
| Platinum | $5-$20 | $20-$40 | $0-$10 |
Cost-Sharing Reduction on Silver can drop copays significantly for income-eligible enrollees.
Related terms
Compare copays across plans — a licensed agent can pull this for free.