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How Manufacturer Rx Coupons Impact ACA Out-of-Pocket Limits

On August 26, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury jointly issued an FAQ to clarify the application of manufacturer coupons to the Affordable Care Act (ACA) cost sharing limits.

In prior guidance issued in the 2020 Notice of Benefit and Payment Parameters, HHS stated that plans and insurers may exclude the value of drug manufacturer coupons from counting towards the ACA’s annual limit on cost sharing when a generic equivalent is available and medically appropriate. The latter portion of this guidance created confusion as to whether drug manufacturer coupons would count towards the ACA’s cost sharing limits in circumstances other than those when a medically appropriate generic drug is available.

In its August FAQs, the departments stated that they would officially address and remedy this confusion in the 2021 Notice of Benefit and Payment Parameters. In the interim, however, the departments clarified that in either situation, they will not enforce this provision against plans and insurers that exclude the value of drug manufacturer coupons from the ACA’s annual limits on cost sharing.

For 2019, the cost-sharing limits/out-of-pocket maximums are:

  • $7,900 for self-only coverage
  • $15,800 for non-self-only coverage

For 2020, the cost-sharing limits/out-of-pocket maximums will be:

  • $8,150 for self-only coverage
  • $16,300 for non-self-only coverage

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