IRS High Deductible Health Plan (HDHP) Rules

Since cost-sharing is allowed with IRS Preventive Drugs, plan participants should be responsible for their copays.

A high-deductible health plan (HDHP) is a plan with a higher deductible than a traditional insurance plan and a maximum limit of the sum of the annual deductible and out-of-pocket medical expenses that you must pay for covered expenses. Out-of-pocket expenses include copayments and other amounts, but do not include premiums.

The Internal Revenue Service (IRS) defines a HDHP as any plan with a deductible of at least $1,350.00 for an individual or $2,700.00 for families1. Additionally, the IRS limits the total yearly out-of-pocket expenses for HDHPs to $6,650.00 for an individual or $13,300.00 for families for in-network services1. These limits do not apply to out- of-network services.

Under the Affordable Care Act (ACA) rules, group
health plans and insurers must provide coverage for certain preventive health services without a deductible. Notice 2013-57, issued by the IRS, addresses the scope of permitted health services that can be provided by a HDHP, under the rules for health savings accounts (HSAs). The IRS issued Publication 969 (2017) which defined preventive care to include the following:*2

  • Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals
  • Routine prenatal and well-child care
  • Child and adult immunizations
  • Tobacco cessation programs
  • Obesity weight-loss programs
  • Screening services

The difference between the IRS HDHP rules and the ACA preventive care coverage requirements is that the IRS rules allow for patient cost-sharing, whereas the ACA preventive care coverage requirements do not.

Monthly costs of the IRS Preventive drugs include:

  • Lantus: $293.00 per vial (dosing is dependent upon number of units patient is taking)
  • Advair Diskus: $392.00 monthly
  • Xarelto: $445.00 monthly
  • Eliquis: $442.00 monthly
  • Trulicity: $725.00 monthly
  • Victoza: $914.00 monthly
  • Prolia: $1208.00 monthly (specialty medication)
  • Forteo: $3260.00 monthly (specialty medication)
  • Prempro: $200.00 monthly

Without cost-sharing, plan sponsors would be responsible for the full cost of these medications. Since cost-sharing is allowed with IRS Preventive Drugs, plan participants should be responsible for their copays.

These rules only apply to HDHP plans to override the patient’s deductible for preventive care services, including pharmaceutical products, so the patient is only responsible for his or her copayment or coinsurance.

Contact WellDyneRx if you are concerned that your plan may be covering these medications unnecessarily.

1. United States Department of the Treasury. Internal Revenue Service. Notice 2004-23: Part III – Administrative, Procedural and Miscellaneous. Internal Revenue Service, 2004. https://www.irs.gov
2. United States Department of the Treasury. Internal Revenue Service. Publication 969: Health Savings Accounts and Other Tax- Favored Health Plans. Internal Revenue Service, 2017. https://www.irs.gov
*this list is not all-inclusive


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