skip to Main Content

CMS Grants Flexibility to Counter Drug Manufacturers’ Coupons

  • This page as PDF


The Centers for Medicare & Medicaid Services released the final Notice of Benefit and Payment Parameters (NBPP) for the 2020 plan year. This annual rule, released today, updates guidance and regulations related to exchanges as well as the broader individual, small group, and large group insurance markets.

The final NBPP:

– Chose not to finalize many of its proposed changes that would have given insurance companies additional flexibility in managing drug formularies, especially for medications where generics are available, and in determining what costs count toward a consumer’s out-of-pocket (OOP) limits. However, it will allow all plans to use copay accumulators to block drug manufacturer payments from counting toward OOP limits—raising costs for some enrollees

– Makes changes to the calculations of advanced premium tax credit eligibility and maximum out-of-pocket limits which could make it harder to qualify for premium assistance and increase consumer exposure to out-of-pocket costs

– Elects not to make changes that could have reduced the number of enrollees whose coverage is autorenewed each year (a population of 1.8M enrollees in 2019) or to limit the practice of “silver loading,” which could increase individual market premiums both inside and outside of the exchanges

– Adjusts out-of-pocket maximums (MOOP) to $8,150 for individual coverage and $16,300 for family coverage ($50 lower than initially proposed)

“CMS remains committed to granting health plans flexibility in managing prescription drug costs,” said Kelly Brantley, managing director at Avalere. “While CMS chose not to adopt some of the more significant changes in the proposed rule, allowing copay accumulators in all commercial plans will leave some consumers paying more out-of-pocket.”

From beginning to end, our team synergy
produces measurable results. Let's work together.

Sign up to receive more insights about Federal Policy
Please enter your email address to be notified when new Federal Policy insights are published.

Back To Top