Depending on a patient's income and assets, they may qualify for either “full” or “partial” extra help. With either, they will never have to pay the full cost of their drugs as long as they take medications that are on their plan's list of covered drugs (formulary) and they buy them at a pharmacy in your plan's network.
If a patient qualifies for partial extra help, their premium is determined by the subsidy “level," which determines whether the patient pays 0%, 25%, 50%, or 75% of the plan premium. The state-specific benchmark amount will also determine their premium. Like all of Medicare, it's a little complicated, but we've broken down the math below.
The Premium Equations:
If the plan Premium is greater than the state-specific benchmark amount:
(State Benchmark) x (Partial Extra Help level) + (Premium - State Benchmark) = Premium
Example: Our patient, Stevie, lives in South Dakota where the benchmark amount is $37.96. She has a 50% subsidy and is interested in signing up for a WellCare PDP, which has a premium of $47.90. Therefore we calculate:
$34.02 x 50% + ($47.90 – $34.02) = $30.89
So when we round to nearest dime, Stevie's premium is $30.90!
If the plan premium is less than the state-specific benchmark amount:
(Plan Premium) x (Partial Extra Help level) = Premium
Example: Say our patient with Partial Extra Help, Elvis, has a 25% subsidy and lives in South Dakota (again, where the benchmark amount is $34.02); SilverScript has a premium of $31.30, which is less than the benchmark. Therefore we calculate:
$31.30 x 25% = $7.83.
When we round to the nearest dime, our patient's premium is $7.80!
We round to the nearest dime because that's how Medicare premiums are calculated 😄
You'll know if a plan's premium is less than the state's benchmark amount when you see the BENCHMARK tag. Learn more about plan tags.
Please note that our numbers may vary slightly from medicare.gov due to minimal differences in percentage-based calculations and estimates.
During the different phases of coverage, patients with Partial Extra Help pay the following:
Patients with partial Extra Help will pay an $82 deductible or the plan’s standard deductible, whichever is cheaper. The patient pays the full cost of their medication until that deductible is met.
Initial Coverage Phase
Patient pays 15% coinsurance or plan copay, whichever is cheaper
Donut Hole / Gap Coverage Phase
Patient pays 15% coinsurance
Catastrophic Coverage Phase
Patient pays $3.35 for generics and $8.35 for brands
Important Note: Partial extra help patients will not have to pay a Part D premium late enrollment penalty if they enroll in a Medicare prescription drug plan after their initial enrollment period. Also, partial extra help patients qualify as Dual Eligible Beneficiaries, which allows them to switch their Medicare plan a maximum of once a quarter throughout the entire year. Learn more about Dual Eligible Beneficiaries.
Once you confirm your patient's subsidy, learn how to enter it into the patient's Amplicare profile before you begin their plan comparison!