Coinsurance is the percentage of the allowed amount that you pay for most medical services and for prescription drugs, when the plan pays less than 100 percent.
After you’ve paid your medical deductible, you pay the following percentages for most services:
- Primary care providers in the core network: You pay nothing for office visits. You may pay 15 percent of the allowed amount for services not considered preventive you receive during a primary care visit, like lab or x-rays.
- Specialty providers in the core or support networks: 15 percent of the allowed amount.
- Out-of-network providers: 50 percent of the allowed amount, and you may be balance billed.
Coinsurance also applies to prescription drugs. Visit What you pay for drugs to learn more.
A copayment is a flat dollar amount you pay when you receive specific services, treatments, or supplies, including (but not limited to):
- Emergency room copay: $75 per visit. See “Emergency room” on the Summary of benefits page for details.
- Facility charges for services received while an inpatient at a core network hospital or mental health, substance use disorder, or skilled nursing facility: $200 per day.