Fixed member-paid amount for an eligible drug or service.
A copayment is a fixed amount the insured or plan member pays toward a covered service, prescription, or treatment while the benefits plan pays the remaining eligible amount according to the plan rules.
Copayments are one of the clearest examples of cost sharing in health and benefits coverage. They affect what the member pays each time a service is used, even when the service is otherwise covered.
In Canadian group and individual benefits plans, copayments often appear in prescription-drug, dental, vision, and paramedical coverage. The plan may require the member to pay a flat amount at the pharmacy counter, dental office, or service provider while the insurer or administrator processes the balance.
This is different from a pure percentage-sharing approach. The copayment stays fixed per claim item or service when the wording says so.
| Term | How the member or insured pays |
|---|---|
| Copayment | Usually a fixed amount per eligible service, claim item, or refill |
| Deductible | Usually an amount absorbed before the plan or insurer begins paying |
| Coinsurance | Usually a percentage share of the eligible cost |
A benefits plan covers an eligible prescription drug but requires a CAD 10 copayment for each refill. The member pays CAD 10 at the pharmacy, and the plan pays the rest of the eligible amount subject to the formulary and plan rules.
The same structure can appear in dental or paramedical coverage. A member may still have coverage in force, but every eligible visit can carry a fixed out-of-pocket amount that remains with the member.
A copayment is not the same as a deductible. A deductible is usually an amount the insured must absorb before the plan begins paying. A copayment can still apply after coverage is active.
It is also not the same as coinsurance. Coinsurance usually splits cost by percentage, while a copayment is usually a flat amount.
Readers also sometimes assume a copayment tells them the whole out-of-pocket rule by itself. In practice, annual maximums, formularies, eligible-expense definitions, provincial plans, and coordination rules can still affect the final member payment.
Drug cards, provincial plans, formularies, and employer-plan wording can all affect how the member’s share is calculated. A label like “copayment” does not by itself tell the reader the whole payment rule.