Medicare copays are fixed dollar amounts you pay when you visit a doctor, fill a prescription, or use certain services — they're separate from your monthly premium

A copay is a set fee you owe at the time of service. Medicare Part B (doctor visits and outpatient care) charges copays for most services. Medicare Part A (hospital stays) does not use copays — instead you pay a deductible once per benefit period, then Medicare covers the rest of your inpatient hospital stay. Part D (prescription drugs) uses copays for each prescription you fill.

The copay amount depends on which type of Medicare you have and what service you're using. Original Medicare (Parts A and B) sets copay amounts by law, so they're the same no matter which doctor you see or which state you live in. Medicare Advantage plans (Part C) set their own copay amounts, which vary by plan and by insurer.

Copays are not the same as coinsurance. Coinsurance is a percentage of the cost you pay after you've met your deductible — for example, you might pay 20 percent of the bill. Original Medicare uses coinsurance for many services, not copays.

Key Takeaways

  • Original Medicare Part B charges a copay for doctor office visits, typically $15 to $25 per visit, though some preventive services have no copay.
  • Medicare Part A hospital stays require you to pay a deductible (not a copay) — the amount changes each year and covers your entire stay once you've paid it.
  • Medicare Advantage plans set their own copay amounts, which can be lower or higher than Original Medicare and vary by plan.
  • Copays are due at the time you receive the service, and you pay them directly to the provider or pharmacy.
  • Many preventive services under Medicare have zero copay, including annual wellness visits, cancer screenings, and certain vaccines.

Copays under Original Medicare Part B

Original Medicare Part B charges a copay for most doctor office visits and outpatient services. The copay is typically $15 to $25 per visit, though the exact amount can vary depending on the type of service and whether the doctor is considered a specialist. You pay this copay at the time of your visit, directly to the doctor's office or clinic.

Some services under Part B do not charge a copay. Preventive services — including your annual wellness visit, cancer screenings (mammograms, colonoscopies, Pap smears), bone density tests, diabetes screenings, and certain vaccines — are covered with no copay if you see an in-network provider. This is true even if you haven't met your Part B deductible yet.

If you see an out-of-network provider under Original Medicare, you may pay more. Out-of-network doctors can charge up to 15 percent above Medicare's approved amount, and you're responsible for the difference. This is called balance billing. Some states have laws that limit balance billing, but not all.

How Part A deductibles work instead of copays

Medicare Part A covers hospital stays, skilled nursing facility care, hospice, and home health services. Instead of copays, Part A uses a deductible — a single lump sum you pay once per benefit period before Medicare starts paying. The deductible amount changes each year. For 2024, the Part A deductible is $1,632 per benefit period.

A benefit period begins the day you enter the hospital and ends 60 days after you leave. If you're readmitted within that 60-day window, you don't pay another deductible — you're still in the same benefit period. If you're readmitted after 60 days have passed, a new benefit period starts and you owe another deductible.

After you've paid the Part A deductible, Medicare covers your hospital stay in full for days 1 through 60. For days 61 through 90, you pay a coinsurance amount per day (not a copay). For days 91 and beyond, you pay a higher coinsurance amount per day. These daily amounts also change each year.

Copays in Medicare Advantage plans

Medicare Advantage plans (Part C) are offered by private insurers and must cover everything Original Medicare covers, but they can structure copays and coinsurance differently. Each plan sets its own copay amounts, so a doctor visit might cost $20 in one plan and $40 in another plan offered by the same company.

When you choose a Medicare Advantage plan, you receive a summary document that lists the copay for each type of service — doctor visits, specialist visits, emergency room, urgent care, hospital stays, and prescription drugs. Read this document carefully before you enroll, because copay amounts are one of the main differences between plans.

Medicare Advantage plans often have lower copays than Original Medicare for routine visits, but they may charge higher copays for specialists or emergency services. Some plans also include an out-of-pocket maximum — a yearly cap on how much you'll pay in copays and coinsurance combined. Once you reach that maximum, the plan covers 100 percent of covered services for the rest of the year.

Prescription drug copays under Part D

Medicare Part D (prescription drug coverage) uses copays for each prescription you fill. The copay amount depends on which Part D plan you choose and which drug you're taking. Plans organize drugs into tiers — typically four or five levels — and each tier has a different copay. Generic drugs are usually on a lower tier with a lower copay, while brand-name drugs are on higher tiers with higher copays.

You pay the copay at the pharmacy when you pick up your prescription. If your drug costs less than the copay, you pay the lower amount. If your drug costs more than the copay, you pay the copay and the plan pays the rest — up to the point where you've spent enough out-of-pocket to enter the "coverage gap" (also called the "donut hole").

The coverage gap is a temporary period where you pay a larger share of drug costs. Once you've spent a certain amount out-of-pocket in a calendar year, you exit the gap and enter catastrophic coverage, where you pay a small copay again and the plan covers most of the cost. The dollar amounts that trigger these phases change each year.

What happens if you can't pay your copay

If you cannot afford a copay, tell the doctor's office or pharmacy before you receive the service. Some providers have financial information programs or can reduce or waive the copay based on your income. Federally may have access to health centers (FQHCs) are required to offer copay reductions for patients with low incomes.

If you're struggling to pay for prescriptions, ask your pharmacy about generic alternatives or lower-tier drugs that might have a smaller copay. You can also contact your Part D plan to ask about programs that help with drug costs — many plans offer copay information for certain medications.

Do not skip a dose or avoid a visit because of the copay without talking to your provider first. Skipping medications or delaying care can lead to more serious health problems that cost much more to treat later.

Copays and your annual deductible

Under Original Medicare Part B, you have an annual deductible of $240 (for 2024) that you must pay before Medicare starts covering most services. Preventive services don't count toward this deductible — they're covered with no copay even if you haven't met your deductible yet.

Once you've paid your $240 Part B deductible, you then pay a copay for each doctor visit or service. The copay does not count toward your deductible — the deductible and copays are separate costs. Medicare Advantage plans may have different deductible amounts, and some plans have no deductible at all.

Part D also has its own annual deductible, which varies by plan. For 2024, most plans have a deductible between $0 and $505. Once you've paid the Part D deductible, you start paying copays for prescriptions.

Frequently Asked Questions

Do I pay a copay for preventive care like cancer screenings?

No. Medicare Part B covers preventive services with zero copay if you see an in-network provider. This includes mammograms, colonoscopies, Pap smears, bone density tests, diabetes screenings, and certain vaccines. You don't have to meet your deductible first.

What's the difference between a copay and coinsurance?

A copay is a fixed dollar amount you pay for a service — for example, $20 per doctor visit. Coinsurance is a percentage of the cost — for example, you pay 20 percent and Medicare pays 80 percent. Original Medicare uses both copays and coinsurance depending on the service.

Can my doctor charge me more than the copay?

Under Original Medicare, if your doctor is in-network, they can only charge the copay (or coinsurance) that Medicare sets. If they're out-of-network, they can charge up to 15 percent more — this is called balance billing. Under Medicare Advantage, your plan's copay is the maximum you owe for in-network care.

Do copays count toward my out-of-pocket maximum?

Under Medicare Advantage plans, yes — copays and coinsurance both count toward your yearly out-of-pocket maximum. Original Medicare does not have an out-of-pocket maximum, so copays and coinsurance can add up without a yearly cap.

What if I use an urgent care center instead of my doctor's office?

Under Original Medicare Part B, urgent care visits are covered the same way as doctor office visits — you pay a copay. Under Medicare Advantage, the copay for urgent care may be different from a regular doctor visit. Check your plan's copay schedule to see what you'll owe.