![]() ![]() The actual text of the final regulation, however, is unclear whether the availability of a generic equivalent is the only circumstance in which a plan can exclude drug coupon savings when calculating costs toward the annual OOP maximum. Where there is no generic equivalent available or medically appropriate, it is less likely that the manufacturer’s coupon would disincentivize a lower cost alternative and thereby distort the market … Therefore, under those circumstances, amounts paid toward cost sharing using any form of direct support offered by drug manufacturers must be counted toward the annual limitation on cost sharing. … he final regulation limits the discretion to exclude manufacturer coupons from counting towards the annual limitation on cost sharing for specific prescription brand drugs that have a generic equivalent, as the availability of a coupon may cause physicians and patients to choose an expensive brand-name drug when a less expensive and equally effective generic or other alternative is available. ![]() When read together, the preamble and the actual text of the regulation seem to indicate that the only time a plan’s OOP cost calculation could exclude enrollees’ savings from a coupon for brand medications is when the medication has no generic equivalent. In light of the increasing cost of prescription drugs, the rule aims to encourage the use of lower-cost generics over the higher-cost brands. The 2020 payment notice allows plans to exclude enrollees’ savings from drug manufacturer coupons for brand medications when calculating costs for the annual OOP limits if the brand drug has a generic equivalent. Section 2707(b) of the Public Health Service Act (PHSA) requires nongrandfathered group health plans and issuers to adhere to the ACA’s annual OOP limits for in-network essential health benefits (42 USC § 18022(c) ACA § 1302(c)(1)). The 2020 payment notice issued earlier this year includes a new provision on how drug manufacturers’ discount coupons affect the ACA’s annual OOP cost-sharing limits. ![]()
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