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TL;DRThe patient co-payment (Zuzahlung) is the statutory amount an insured adult pays a pharmacy when a prescription medicine is dispensed at statutory health insurance (GKV) expense. Under §61 SGB V it is 10 percent of the price, at least 5 and at most 10 euro, never more than the medicine itself.
The legal cross-reference matters. §31 Abs. 3 Satz 1 SGB V obliges insured persons die das achtzehnte Lebensjahr vollendet haben to pay, for every medicine and dressing prescribed at GKV expense, the amount that results from §61 Satz 1, jedoch jeweils nicht mehr als die Kosten des Mittels. §61 sets the formula, §31 Abs. 3 applies it to medicines and exempts everyone under 18. The pharmacy collects the co-payment and forwards it to the sickness fund, so the amount reduces what the fund pays, it is not extra revenue for the pharmacy.
The §61 rule is a single clamped percentage. Work it in three steps.
The worked results below follow directly from that clamp. They are illustrative prices, not real articles.
| Pharmacy retail price | 10 percent | Co-payment after the clamp | Reason |
|---|---|---|---|
| 4.00 euro | 0.40 euro | 4.00 euro | Below 5 euro, so the co-payment equals the full price |
| 8.00 euro | 0.80 euro | 5.00 euro | Floor of 5 euro applies |
| 50.00 euro | 5.00 euro | 5.00 euro | 10 percent sits exactly on the floor |
| 80.00 euro | 8.00 euro | 8.00 euro | 10 percent between floor and ceiling |
| 150.00 euro | 15.00 euro | 10.00 euro | Ceiling of 10 euro applies |
The same §61 regime governs other benefits at different rates (10 euro per hospital day, 10 percent plus 10 euro per prescription for Heilmittel and home nursing care), but for a dispensed medicine only the 10-percent-with-5-to-10-euro band is relevant.
These three terms are routinely blurred, yet they answer three different questions: what the patient pays as a matter of course, what they pay when a product is priced above its reimbursement ceiling, and when they pay nothing at all. They can apply to the same pack at the same time.
| Co-payment (Zuzahlung) | Aufzahlung / Mehrkosten (excess) | Zuzahlungsbefreiung (exemption) | |
|---|---|---|---|
| Legal basis | §61 SGB V with §31 Abs. 3 Satz 1 | §31 Abs. 2 SGB V (fund pays only up to the Festbetrag) | §62 SGB V (Belastungsgrenze) and §31 Abs. 3 Satz 4 |
| What it is | The statutory 10 percent, 5 to 10 euro co-payment on essentially every GKV medicine | The difference the patient pays when the price exceeds the Festbetrag, or when a costlier non-reimbursable product is chosen | The point at which no co-payment is owed at all |
| Amount | Clamped, 5 to 10 euro, never above the price | The full excess over the ceiling, uncapped | Zero |
| Counts toward the Belastungsgrenze | Yes | No | Not applicable |
| Avoidable | Only through an exemption | Yes, by dispensing a product at or below the Festbetrag | - |
Two practical points follow. The Aufzahlung is uncapped and does not count toward the annual hardship ceiling, which makes it the more painful of the two for a chronically ill patient. And Mehrkosten is the common umbrella term for any amount above the reimbursable price that the patient bears, so it covers both the Aufzahlung above the Festbetrag and the excess when a patient insists on a pricier product instead of the fund's rebate-contract item.
There are three distinct exemption routes, and they operate independently.
Only co-payments actually paid count toward the Belastungsgrenze. An Aufzahlung above the Festbetrag does not, which is why exempt patients can still face out-of-pocket costs on a costly branded pack.
A Rabattvertrag under §130a Abs. 8 SGB V feeds two separate reliefs. First, the product-level route above: if a rebate makes the effective price sit at least 20 percent below the Festbetrag, the GKV-Spitzenverband can declare the article zuzahlungsfrei for everyone (§31 Abs. 3 Satz 4). Second, §31 Abs. 3 Satz 5 lets an individual fund die Zuzahlung um die Hälfte ermäßigen oder aufheben for other medicines covered by a §130a Abs. 8 agreement, again only where savings are expected. Both are permissive: the statute says kann, so whether a given pack is halved or waived depends on the fund's decision, not on the rebate alone.
The co-payment status reaches the platform through the licensed ABDA article master data. It is not a manual calculation: the co-payment amount and the exemption flags sit per PZN in the price and reimbursement blocks, next to the Festbetrag, so the patient's real out-of-pocket position is visible without leaving the article.
One honest limitation: the exemption flag records whether an article is currently zuzahlungsfrei, it does not compute an individual patient's Belastungsgrenze. That depends on a person's gross income and the co-payments already made in the year, which sit with the sickness fund, not in the article master data. The authoritative, continuously updated list of co-payment-exempt medicines is the one the GKV-Spitzenverband publishes under §31 Abs. 3 Satz 4.
