You may pay different amounts for drugs throughout the year if you have Extra Help. With Extra Help, you will always pay either your Extra Help copayment or the amount that your plan charges people without Extra Help, whichever is cheaper.
However, since the amount a plan charges its members for prescriptions can change throughout the year, the cheaper amount may vary over time.
Example. Mr. S has full Extra Help and his monthly income is above $1,005, so his copays are $3.35 for generics and $8.35 for brand-name drugs. However, his Medicare private drug plan only charges its members a $1.25 copay for the generic drugs Mr. S. takes. Therefore, Mr. S should pay a $1.25 copay for his generic drugs, since $1.25 is cheaper than his $3.35 Extra Help copay. Once Mr. S’s total drug costs put him in his plan’s coverage gap—when plan member’s without Extra Help must pay 100% of the cost of their drugs—Mr. S’s out-of-pocket costs for his generic drugs would go up to $3.35, since his $3.35 Extra Help copay is cheaper than 100% of the cost of the drug.
If Mr. S had full Extra Help and his monthly income was below $1,005, his copays would be $1.25 for generics and $3.70 for brand–name drugs or his plan’s standard copay or coinsurance, whichever is cheaper. If Mr. S had partial Extra Help, he would pay a 15% coinsurance for his prescription drugs or his plan’s standard copay or coinsurance, whichever is cheaper.
Your out-of-pocket costs will also change once you reach catastrophic coverage. If you have Extra Help you will reach catastrophic coverage after your out of pocket drug costs reach $5,000 in 2018.
Once you reach catastrophic coverage, if you have full Extra Help you will pay nothing for drugs on your plan’s formulary for the rest of the calendar year. If you have partial Extra Help (you have been paying 15% of the cost of your drugs or your plan’s standard copay or coinsurance, whichever is cheaper), you will pay $3.35 for generic drugs and $8.35 for brand-name drugs for the rest of the calendar year.
Note: Catastrophic coverage works differently if you do not have Extra Help.