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While premiums go toward the total cost of the care you receive, health care costs add up to more than your premiums cover. To keep premiums lower, plans typically have a deductible that you pay if you get care. You pay that before your insurance kicks in. If you are healthy and need less care, it means you’ll pay less overall.
Here’s the other out-of-pocket amounts you may pay when you get care.
A copay is a fixed price you usually pay when you get care.
The amount of the copay can change depending on where you go. You may have a $30 copay for a primary care doctor visit. A specialist visit may take a $50 copay. A trip to the ER could be as much as a $200 copay. Take a look at your member ID card. It will have a list of your copays for different types of visits.
There are two times you may not have a copay. When you have an annual preventive exam, your health plan will cover the whole bill. That means you don’t pay anything for your visit.*
The other time is after you’ve met your deductible. Since coinsurance is your portion for the cost of your treatment, you may not have to pay a separate copay for the visit, as well.
Coinsurance is a percent, rather than a dollar amount, you pay of the covered services when you get care.
Your member ID card shows what your coinsurance percentage is. It will also show what your health plan pays. In most cases, yours is the smaller percentage. For example, if you have a 40% coinsurance for a specialist visit that costs $100, the part you’ll be asked to pay will be $40.
If you pay more, it is likely because both a copay and coinsurance are required.
How are copays and coinsurance used together? More than one kind of payment may be needed if more than one service is part of a visit.
Say you go to the dentist for a cleaning. They find a cavity and so you have a filling while you are there. The visit to the dentist for general cleaning and checkup may have a $50 copay. But the cost of the filling may have a 20% coinsurance. The two payments will be added for your total charge.
How are copays applied to prescription drugs? There are three different levels of copays in a prescription drug plan. Generic drugs have the lowest copay, since they are the least expensive. A higher copay is usually charged for name brand drugs. If you are on a specialty drug or are taking a drug that isn’t in your plan’s approved drug list, you may pay an even higher copay. It always helps to know the details of your drug plan before you pick up your prescription from the pharmacy or place a mail order request.
It can be hard to know how to use your health plan, so you get the most out of it. Understanding everything you can is the key to saving money and not being surprised when you go to check out or get a bill in the mail.
As always, if you have questions about your coverage before, during or after you use it, call the customer service number on your member ID card to speak with a customer service advocate.
*Some plans may not cover preventive care at no charge. Login to Blue Access for Members to check your benefits if you aren’t sure.
Originally published February 2, 2016; Revised 2019
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