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Small group Important Business Updates |
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Formulary update: Humira to be replaced by biosimilar products
Starting on April 1, 2024, the Advanced Control Plan – Aetna formulary will no longer include Humira (adalimumab). Instead, members will have coverage for a selection of biosimilar adalimumab products. These products are lower cost than Humira. This change impacts all Small Group Aetna Funding AdvantageSM and Aetna® Fully Insured 51-100 plans, which all use the Advanced Control Plan – Aetna formulary. Members’ prior authorizations will automatically transfer to an available biosimilar product for any claims after April 1st, 2024. A new prescription for the biosimilar will be needed, but many pharmacies, including CVS Specialty® Pharmacy, will contact the provider to handle the change on the member’s behalf. We will notify impacted plan sponsors of this change in February, using this letter. |
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Over-the-Counter Health Solution: Updated member account registration instructions
With the Over-the-Counter (OTC) Health Solution, members get a $25 allowance each quarter to spend on hundreds of CVS® brand non-prescription health and wellness support products.* Members can still use their in-store benefit as usual, but will need to create an account to access program catalogs, track allowance balances online and use the OTC Health Solution app.
To register, members will need to provide: - A valid email address
- Basic personal information
- Their Aetna member ID number, including the suffix identifying which subscriber or dependent they are on the plan.
Refer to the guide for details on creating a member account. For more information on the OTC Health Solution, be sure to review the flyer or contact Customer Service at 1-888-628-2770. |
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*$25 allowance each quarter to use on select CVS Health® brand products. Unused allowance does not carry over to the next quarter. This benefit is available to: AFA groups with effective dates of 9/1/23 or later, 51-100 Fully Insured groups in FL, KS and TX starting with October 1, 2023 effective or renewal dates and 51-100 Fully Insured groups in AZ, CT, DC, DE, GA, IA, IL, MA, MD, ME, MI, NC, NE, OH, OK, PA, SC, TN, VA, WV starting with April 1, 2024 effective or renewal dates. This benefit is not available to Fully Insured groups in MO or NJ. |
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Fully Insured 51 – 100 product portfolio updates
To offer more consistency in our Fully Insured portfolios across different markets, we have updated and added new plans designs. Availability includes: - Starting with 10/1/23 effective and renewal dates in FL, KS, MO, and TX
- Starting with 4/1/24 effective and renewal dates in AZ, CT, DC, DE, GA, IA, IL, MA, MD, ME, MI, NC, NE, NJ, OH, OK, PA, SC, TN, VA, and WV
However, there are still differences between states, so be sure to check benefit grids and plan design documents for more state details. The member program updates pertain to the following products: - Over-the-Counter Health Solution®*
- $0 CVS Health Virtual Care™**
- $0 CVS Health Virtual Primary Care™***
- $0 preferred diabetic benefit†
Refer to the flyer for details on the program offerings. |
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*$25 allowance each quarter to use on select CVS Health® brand products. Unused allowance
does not carry over to the next quarter. This benefit is not available in MO or NJ.
**Not available on plans offered to groups based in AZ; certain locally based network plans in FL, KS, MO, and TX; or indemnity plans. Applicable plan cost sharing applies to groups located in CT and IL.
***Not available on plans offered to groups based in AZ or IL; certain locally based network plans; or Health Network Only/Open HMO and indemnity plans. Applicable plan cost sharing applies to groups located in CT.
†Not available in CT, DC, DE, IL, MD, ME, NJ, OK, TX, VA, or WV. |
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Gag Clause Prohibition Compliance Attestation completed and filed
As communicated in the September 2023 newsletter, Aetna completed and filed the required annual Gag Clause Prohibition Compliance Attestation (GCPCA) template on behalf of your customers. They were submitted to CMS by the December 31, 2023, due date. CGPCA states that employer-sponsored group health plans are prohibited from entering into agreements with a health care provider, network or association of providers, Third Party Administrator, or other service provider where the plan is restricted from accessing and sharing certain information. For more information on the GCPCA, refer to the FAQs. |
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2023: A year in review
The 2-100 marketplace had its fair share of changes in 2023, and you were an important part of it all. Let’s look at some of the key highlights from this past year, which will continue to simplify your workload and set you up for success in 2024: - 2023 kicked off with a major carrier announcing they were leaving the 2-100 marketplace. We developed a strategy to facilitate a smooth transition for these groups, while you worked diligently to ensure they landed with a plan that was the right fit for them.
- We made enhancements that streamline some of our processes, including:
- The AFA sold case process (thank you for submitting all the needed information!)
- OneCensus template, which provides an easy way to submit your census for new business and renewals for AFA/FI and ACA
- Internal improvements that helped give you quotes faster during fourth quarter.
- Amid all that change, we aligned our portfolios across products and now quote both AFA and Fully Insured on your 51-100 groups, allowing you to decide the best option for your clients.
We appreciate your great partnership and commitment in 2023! We continue to focus on ways to innovate and improve as we transition into the new year. |
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