If you have Extra Help, throughout the year you will pay either the Extra Help copayment or your plan’s copay for your prescription drugs. You always pay the lower cost between the two. Note that plan copays for prescriptions may change during the year, meaning at times the price for your prescription drugs may differ.
Example: Mr. S has full Extra Help and a monthly income above $1,061, so his Extra Help copays are $3.40 for generics and $8.50 for brand-name drugs. However, his plan copay for his generics is $1.25. Mr. S will therefore pay the plan copay of $1.25 because it is cheaper than the Extra Help copay of $3.40. Once Mr. S’s total drug costs put him in his plan’s coverage gap Mr. S’s out-of-pocket costs for his generic drugs would increase to $3.40, since the $3.40 Extra Help copay is cheaper than 100% of the cost of the drug.
If Mr. S had full Extra Help and a monthly income below $1,061, his copays would be $1.25 for generics and $3.80 for brand-name drugs, making his generic Extra Help copay less costly than the plan copay of $1.25. This means that Mr. S would pay the Extra Help copay throughout the year. If Mr. S had partial Extra Help, he would pay a 15% coinsurance for his prescription drugs or his plan’s standard copay.
Your out-of-pocket costs also change when you reach catastrophic coverage ($5,100 out of pocket in 2019). Those with full Extra Help who reach catastrophic coverage generally will pay nothing for covered drugs for the remainder of the calendar year. Those with partial Extra Help will pay $3.40 for generic drugs and $8.50 for brand-name drugs for the remainder of the calendar year.