When you run your California health insurance instant quote, you will frequently see the term Copay. Unless you are pretty well versed with health insurance terminology (a sad state of affairs), this term might be new to you. Let's take a look at it and where and when it comes into play.
First, what's the official definition of a Copay:
Co-payment
The portion
of charges
you pay to
your
provider for
covered
health care
services in
addition to
any
deductible.
For example,
$20 for an
office visit
or $15 for a
prescription
drug. It is
similar to
coinsurance,
but it is a
dollar
amount
instead of a
percentage
of the
charges.
So it is a fixed amount that you will pay for a particular service. There are two main areas that copays are traditionally used in health policies broken out separately from the main deductible of the policy. This means you get the copay benefit immediately. Please see below for how HSA or Health Savings Account plans treat this.
Office
Copay
This is
a main
component
of the
benefit
summaries
you will
see
when you
receive
an
instant
health
quote.
With
most
plans on
the
market,
you will
pay a
fixed copay
for the
office
consultation.
For
example,
you may
see
"$10"
under
the
office
visit
column.
This
usually means
that you
will pay
$10 when
you see
a
doctor.
One
important
item...the copay
only
covers
the
consultation
itself.
If the
doctor
requests
labs or
performs
other
procedures
(such as
a
dermatologist
performing
a skin
biopsy),
that
procedure
is
usually not
covered
under
the
office copay.
It will
either
have a
separate
copay
(typical
with
HMO's);
be
subject
to a
plan
deductible;
or
subject
to
co-insurance
percentage
sharing.
Labs are
also in
addition
to the copay
amount
you pay.
Usually
there is
a flat
copay
amount
for
general
physicians
and
specialists
on the
California
health
insurance
market.
Prescription
Copays
This is
also a
main
component
of the
health
benefit
summary
you will
view
when
requesting
an
instant
quote.
Most
plans on
the
market
make a
distinction
between
three
types of
prescription
costs.
They
typically
will
have a
lesser
amount
(generally
$10) for
Generic
drugs.
Generic
drugs
are less
expensive
than the
second
category,
Brand
Name
Formulary.
Most
plans
have a
higher copay
amount
for
Brand
Name
Formulary
and
these
days,
many
plans
also
have a
separate
deductible
for
Brand
Name
Formulary.
This
means
you will
need to
pay for
the drug
out of
pocket
until
you meet
your
calendar
year
deductible;
after which,
you will
then
have the
Brand
name
copay
(usually
$30-40
for a
monthly
supply).
There is
also a
separate
Brand
Name
Non-formulary
category.
These
are
Brand-name
drugs
which
are
deemed
by the
health
insurance
carrier
to be
equally
effective
but much
more
expensive
than a
comparable
Brand
Name
Formulary
drug.
Formulary
just
means a
list of
drugs
that the
health
insurance
carriers
deems to
be
both effective
and
cost-effective.
For
Brand
Name
non-formulary,
you may
have to
pay a
percentage
of the
cost and
not have
a copay
at all.
Other
services
Copays
Usually,
you only
have
copays
for
other
services
on HMO
plans.
That is
a major
benefit
of HMO
plans
and also
a reason
why they
have
become
so
expensive.
If you
can get
an $800
MRI for
a $10
copay....well
eventually
the
premium
will go
up
significantly.
It's
common
to also
have a
copay
amount
for ER
visits.
Emergency
room
care is
especially
expensive
so the copay
which
can
range
from $75
and up
offsets
this
costs
and
hopefully
adds an
incentive
for
members
to
address
issues
before
they
become
emergencies.
Health
Savings
Account
HSA and
copays
HSA
plans
are
different
from
traditional
PPO or
HMO
plans in
that
most if
not all services
are
subject
to the
main
deductible.
With
traditional PPO or
HMO
plans,
the
office
visit and RX
copays
are
typically
broken
out
separately
from the
main
plan's
deductible.
Even
though
the HSA
plan
summaries
might
show
copays,
these
copays
are not
available
until
the
higher
deductible
is met
so it's
best to
assume
you do
not have
the
copays
when
comparing
the
plans.
Other important concepts to help you understand your health insurance quote are:
Co-insurance
Deductible
max out
of
pocket
To
run your
instant
health
insurance:
California
Individual
Family
health
insurance
quote
California
Small
Group
health
insurance
quote
