Horizon to Replace Humira and Stelara with Biosimilars Starting July 1, 2025
Effective July 1, 2025, Horizon removed Humira® and Stelara® from its managed formularies, replacing them with lower-cost biosimilars. Members using these medications will need to transition to alternatives such as Hadlima, adalimumab-aaty, Steqeyma, or Yesintek—unless deemed medically necessary to remain on the original drugs. Horizon is notifying providers and pre-authorizing approved biosimilars in advance to ease the switch. Affected members will receive notices based on formulary status changes.
AmeriHealth and IBX to End Zepbound Coverage for Obstructive Sleep Apnea
AmeriHealth and Independence Blue Cross will remove Zepbound® (tirzepatide) from their Select and Value formularies for obstructive sleep apnea (OSA) starting August 1, 2025, or upon plan renewal. Coverage for new prescriptions ended May 1. The change reflects limited clinical evidence for OSA treatment beyond weight loss and aligns with the exclusion of weight loss drugs. Affected members will be notified by June 1 and will be responsible for the full cost if they continue treatment. Covered alternatives include CPAP, BiPAP, oral devices, nerve stimulators, and surgical options when appropriate.
Aetna CVS Health to Exit Individual Market in 2026
Aetna CVS Health will exit the Individual & Family Plans (IFP) exchange market effective January 1, 2026. Coverage will remain unchanged through the end of 2025, with final active coverage ending December 31. Member notification letters began mailing June 6, 2025. During Open Enrollment, affected members must choose a new 2026 plan or be automatically transitioned to another carrier. Aetna will work with brokers and members to support a smooth transition. All 2025 claims will be honored; 2026 claims must go through the new carrier.
PBG Video: Pairing an HSA with High-Deductible Health
Reminder! Form 5500 Filing Due July 31 for Calendar-Year Plans
Employers subject to ERISA must file Form 5500 for each benefit plan by July 31, 2025, if the plan follows a calendar year. An automatic extension to October 15 can be requested by submitting Form 5558 by the same date. Small welfare plans with fewer than 100 participants may be exempt. Late filers risk penalties of up to $2,739 per day, though the DOL’s Delinquent Filer Voluntary Compliance Program offers reduced fines. Employers should coordinate with plan administrators and review exemption eligibility to ensure compliance.
Compliance Corner! Reminder: PCORI Fees Due by July 31 for Self-Insured Plans and HRAs
Plan sponsors of self-insured health plans, including HRAs and level-funded arrangements—are required under the ACA to pay annual PCORI fees to fund health research. These fees apply to plan years ending between October 1, 2012, and September 30, 2029, and must be filed using IRS Form 720 by July 31 each year. The fee is based on the average number of covered lives using one of three IRS-approved methods. Separate reporting is required for stand-alone HRAs and those integrated with insured plans.