Deductibles, copays and coinsurance are all terms to describe money you pay toward health care services and prescription drugs when you have a health insurance plan. There’s also a limit to how much you pay. It’s called an out-of-pocket max, or maximum.

Deductible

A deductible is the amount of money you pay for health care services before your plan kicks in and starts paying. For most services, you'll pay full cost until you reach the deductible. After you reach your deductible, you’ll still have to pay any copays or coinsurance. Some services will be covered by your plan before you reach the deductible.

Most Medicare Advantage plans have separate medical and pharmacy deductibles. That means that in addition to the medical deductible, you might also have a Part D prescription drug deductible that you’ll need to meet before your plan starts covering your medications.

Copays

A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. 

Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible. You may also have a copay after you pay your deductible, and when you owe coinsurance. 

Your Blue Cross Blue Shield of Michigan Member ID card may list copays for some visits. You can also log in to your online account, or register for one, on our website or using the mobile app to see your plan’s copays.

Out-of-Pocket Maximum

Your out-of-pocket max, or maximum is the most you’ll have to pay during a policy period, usually a year, for health care services.

How it works

What you pay toward your plan’s deductible, coinsurance and copays are all applied to your out-of-pocket max.

Once you reach your out-of-pocket max, your plan pays 100 percent of the allowed amount for covered services.

If your plan covers more than one person, you may have a family out-of-pocket max and individual out-of-pocket maximums. That means:

• When the deductible, coinsurance and copays for one person reach the individual maximum, your plan then pays 100 percent of the allowed amount for that person
• When what you’ve paid toward individual maximums adds up to your family out-of-pocket max, your plan will pay 100 percent of the allowed amount for health care services for everyone on the plan

What doesn’t go toward your out-of-pocket max

• Amounts you pay for health care services that aren’t included in your plan’s benefits
• Your monthly payment, or premium, if you buy your own health insurance