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What is a copayment?

A copayment is the fixed amount you must pay after you’ve paid the deductible for each medical visit to a participating doctor or other health care provider, usually at the time of service.

Understanding Copayments


Understanding what you pay for your health care is an important part of understanding your coverage.

Your copayment is a fixed dollar amount you pay each time you get care from your doctor, another type of health care professional or a hospital. Your copayment amount can vary depending on the type of health plan you have and which doctor, specialists or hospital you see.

Let’s see how a copayment works.

Sarah has a sore throat and gets an appointment with her in-network family doctor. At the doctor’s office, she pays the copayment amount listed on the front of her member ID card. For Sarah’s plan, the copay is $10 for an in-network family doctor. Once the claim is submitted by her in-network family doctor and processed by Horizon Blue Cross Blue Shield of New Jersey, an Explanation of Benefits statement or EOB is generated. The EOB shows how much her plan paid, how much she paid for her copayment and how much she owes for the visit if applicable.

What you need to know about copayments?

Your copayment amounts differ depending on the type of doctor, hospital or other health care professional you visit.

For example, the copayment to see a specialist in your plan may be higher than the copayment to see your primary care physician. Your copayment may also differ if you go out-of-network. Copayments are one component of your out-of-pocket expenses. Other out-of-pocket expenses may include your coinsurance, annual deductible and the cost for services not covered by your plan.

Copayments, coinsurance and deductibles: Understanding the differences.

Your plan could have a copayment, coinsurance or annual deductible. It does not always include all three.

Copayment. What you pay each time you receive care.

Coinsurance. What you pay after you’ve met your deductible.

Deductible. What you pay before your health insurance kicks in.

What is my maximum out-of-pocket?

Your maximum out-of-pocket is the highest amount you will have to pay each year. Once you meet your maximum out-of-pocket, your insurance will pay in full for all covered services and you will no longer pay a copayment, coinsurance or a deductible for the remainder of the plan year.

Maximum out-of-pocket can vary depending on type of plan and the number of dependents covered.

To learn more about your out-of-pocket costs and your health insurance benefits, visit

If you need help finding information about your benefits, claim status and more, sign in to our secure Member Online Services at to: read our FAQs, send us a question through our secure email or ask a question through Chat during normal business hours.

Horizon Blue Cross Blue Shield of New Jersey remains committed to helping you understand your benefits.

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Last updated:

Jan 07,2022