Copayments and Exemptions: What Medicines Really Cost

If you have German statutory health insurance, you pay a statutory copayment (Zuzahlung) for many medicines — but far less than most people think. This guide uses simple worked examples to explain how the copayment is calculated, where your personal out-of-pocket ceiling (Belastungsgrenze) lies and how, step by step, you can be exempted from further copayments.

1. How the statutory copayment is calculated

For prescription medicines that your statutory health insurer pays for, you make a copayment at the pharmacy. The formula is simple and the same for everyone — it is set out in Section 61 SGB V (the German Social Code, Book Five):

• you pay 10 % of the sale price yourself,
• but at least 5 €,
• and at most 10 €,
• and in no case more than the medicine costs in the first place.

That sounds abstract, but a few figures make it instantly tangible. Look at how the same percentage plays out at different prices:

So an expensive medicine never costs you more than 10 € in copayment — the rest is covered by your insurer. A very cheap remedy never costs you more than its actual price. Your share only lands between 5 € and 10 € when the price is between 50 € and 100 €.

2. Reference price and extra costs: the second layer

Besides the copayment, there is a second thing that affects your wallet — and one that is often confused with it: the extra costs above the reference price (Mehrkosten über dem Festbetrag). For many active ingredients, the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) sets a reference price (Festbetrag) — the maximum price the insurer reimburses for that medicine. If the specific product costs exactly that or less, all is well: you pay only the normal statutory copayment.

But if your product is above the reference price, you pay the difference out of your own pocket as well — on top of the copayment. These extra costs do not count towards your out-of-pocket ceiling and cannot be reclaimed. The key point: there is almost always a product with the same active ingredient at the reference price, for which no extra costs arise. Ask specifically for it at the pharmacy.

You can read more about how products with the same active ingredient differ in the guide Generics vs. originals.

3. Aut idem: why you often get a different product

You may know the situation: you pick up your usual medicine and suddenly get a different pack with the same active ingredient. Behind this is "aut idem" (Latin for "or the same"). As long as the prescribing practice does not explicitly rule it out, the pharmacy may — and must — dispense a product with the same active ingredient, usually cheaper, for which your insurer has a rebate contract (Rabattvertrag).

For you this is usually an advantage: rebate medicines are often exempt from copayment or safely within the reference price, so no extra costs arise. Active ingredient, quantity and strength stay the same — only the manufacturer, the pack and sometimes the colour of the tablet change. Only if there are compelling medical reasons can the practice tick the aut idem box and specify a particular product.

4. The out-of-pocket ceiling: worked examples

No one should be financially overwhelmed by copayments. That is why there is the out-of-pocket ceiling (Belastungsgrenze) under Section 62 SGB V: you do not have to pay more than 2 % of your annual gross income for living expenses in copayments. For the chronically ill who are in continuous treatment for the same serious illness, the limit drops to 1 %.

"Copayments" here means all the statutory copayments in the year combined: for medicines, therapeutic and assistive devices, hospital stays and transport costs. Let's work it through with a concrete example.

An everyday example: suppose you earn 30,000 € gross a year and are not chronically ill. Your out-of-pocket ceiling is 600 €. As soon as your collected copayments in the calendar year reach that 600 €, you can be exempted from all further copayments for the rest of the year. If you are in continuous treatment for a chronic illness, the limit halves to 300 €.

5. When do I count as "chronically ill"?

The 1 % limit is worth real money — so it is worth asking whether you can claim it. You count as seriously chronically ill under the Chronic Illness Directive (Chroniker-Richtlinie) if you have been in medical treatment for the same illness for at least one year, at least once per quarter, and in addition meet at least one of these criteria:

• There is a need for long-term care (care level 3, 4 or 5).
• There is a degree of disability of at least 60 % or a reduction in earning capacity of at least 60 %.
• Continuous medical care is required, without which the illness would worsen in a life-threatening way, shorten life expectancy or permanently reduce quality of life.

Whether you meet the requirements is usually confirmed to the health insurer by your treating practice. For how to organise everyday life with a long-term illness, see the guide Living with a chronic illness.

6. Step by step to your exemption

The route to an exemption is straightforward — above all it asks one thing of you: that you collect your receipts throughout the year. Here is how to proceed:

• Collect receipts. Ask for a receipt at the pharmacy and for every copayment, and keep it all year — ideally in a receipt booklet (Quittungsheft), which many insurers provide free of charge.
• Add up the amounts. Add together all the statutory copayments for the year. As soon as you reach your personal limit, the application becomes worthwhile.
• Submit the application. Send the completed form to your insurer together with the receipts. The health insurer checks it and issues you an exemption card (Befreiungskarte) for the rest of the calendar year.
• Reclaim what you overpaid. If you have already exceeded the limit before you submit the application, the insurer refunds the amount you overpaid.

7. Common misunderstandings about copayments

A few persistent myths surround copayments and exemptions. Here are the three most important, cleared up:

• "The copayment is always 10 €." Wrong — 10 € is only the maximum amount. For cheap medicines you pay less, but at least 5 € (unless the remedy itself costs less).
• "I can reclaim extra costs." No. Only the statutory copayment counts towards the out-of-pocket ceiling. You bear the difference to the reference price yourself — which is why it pays to choose a reference-price-compliant product.
• "The exemption automatically carries over." No. The exemption card only ever applies to the current calendar year. In the new year the count starts from scratch, and you may have to apply again.

Because many copayments arise spread across the year, it helps enormously to keep track. A well-kept overview of your medicines and costs is half the battle — the guide Keeping a medication list shows you how to manage it.

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