2 Copays For One Office Visit

  1. Specialist Copay Vs Office Copay
  2. Two Copays For One Office Visit

Tier 1 (Generics): $15 copay 1 Tier 2 (Preferred brand): $90 copay Tier 3 (Non-preferred brand): $125 copay Specialty Pharmacy 2: Tier 4 (Preferred specialty): $65 copay Tier 5 (Non-preferred specialty): $85 copay Retail Pharmacy: 45% of our allowance Mail Service Pharmacy: Not. Copay amount for each visit or test: $15: Type of outpatient care: Specialty care services (like a visit to a hearing specialist, eye doctor, surgeon, or cardiologist) Copay amount for each visit or test: $50: Type of outpatient care: Specialty tests (like an MRI or CT scan) Copay amount for each visit or test: $50. Notify your local MDHHS office if you have other health insurance or if your insurance changes. You can visit the myHealthPortal website to make updates or call the Beneficiary Help Line at 1-800-642-3195 to report other health insurance. The lowest copays will be for office visits to a primary care physician, physician’s assistant or nurse practitioner. If you need to visit urgent care or see a specialist like a cardiologist or an immunologist, your copay will be a little higher. The most expensive copays will come when you visit the emergency room. Office Visit: $20 Copayment. Office Surgery: $20 Copayment (If there are both an Office Visit charge and an Office Surgery charge by a Participating Provider in a single visit, only one copayment will apply, in addition to any copayment due for Radiology/Laboratory Tests.) Radiology, Single or Series; Diagnostic Laboratory Tests: $20 Copayment.

Copay Tips

  • You are typically required to pay your copay to your doctor’s office at the time of your visit
  • The office visit copay is a set dollar amount (e.g. $15 per visit)
  • Your deductible may not apply, depending on your health plan design

You will not pay copays for preventive care office visits. Copays are for the office visit only, and do not cover any additional services you might receive during your visit (e.g. lab work or X-rays). Any additional services are subject to your deductible and coinsurance, until you reach your out-of-pocket limit. Here are examples of office visit types and the applicable copays.

Pcp office copay

Office Visit Type

$15 Primary Care Visit

$25 Specialty Visit

Family Practice

General Practice

Internal Medicine


(if your plan provides in-network midwives)

Nurse Practitioners

Physician Assistant


Urgent Care


Home Health Visit

Subject to deductible and coinsurance

Subject to deductible and coinsurance

Palliative Care Visit

For PCP Only

For Specialist Only

Vision Exam

Pre/Postnatal Visits

For family practice with obstetrics or OB/GYN

For maternal/fetal specialist

Mental Health Visits/Therapy

Physical Therapy

Occupational Therapy


Speech Therapy

Other Practitioner

*If all prenatal visits are billed as a package at the end of pregnancy, then your deductible and 10% coinsurance apply. Check with your doctor’s office for more information.


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Ask The Expert, August 14, 2003

For Medicare patients, Medicare assigns a copay for each covered service under the ambulatory payment classification (APC) system. If a patient needs more than one APC service in a single day, the patient will legally owe more than one copay. However, according to section 204(a) of the Balanced Budget Refinement Act, the coinsurance amount for a hospital outpatient procedure cannot exceed the amount of the inpatient hospital deductible for that year.

Specialist Copay Vs Office Copay

For insured patients, check your insurance contracts. The information you are looking for is not in the law. The insurance contract will specifically tell you whether a provider may bill for two or more copayments for services rendered on the same day. For example, some insurance companies let you bill for an annual physical exam, a sick visit, and laboratory tests all in the same day. Your contract is most likely in compliance with your state laws if it allows you to collect multiple copays on the same day. Contact your state's insurance commissioner for further information.

This question was answered by Susan Welsh, CPC, an independent consultant based in Nashville, TN, and Marianne Labahn, RN, BSN, MS, director of compliance and chargemaster for the Cancer Treatment Centers of America in Arlington Heights, Ill.

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Two Copays For One Office Visit

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