EpiPen mandate
|
The cost-share for epinephrine auto-injector devices (EpiPens) will be capped at $100 per plan year. Formulary management and prior authorizations may apply. Deductible applies for HSA-qualified high deductible health plans.
|
Outpatient donor human milk mandate
|
Coverage of pasteurized donor human milk has been extended to outpatient locations. Subject to the DME cost-share. Prior authorization may apply.
|
Outpatient behavioral health access mandate
|
Members unable to access outpatient mental health care and substance use services within specified time frames may be able to access a nonparticipating provider with prior authorization.
|
Health funding accounts
|
Lifetime Benefits Solutions will be the exclusive provider of funding accounts in 2026. Pairing a CDPHP health plan with a funding account provides tax advantages and cost savings for employers
and employees.
|
Hearing aid vendor
|
Hearing Care Solutions is changing it’s name to TruHearing. All related benefits remain the same.
|
Musculoskeletal and cardiology services
|
Non-emergent musculoskeletal (including Interventional Pain Management) and cardiac services (including cardiac devices and interventional cardiology) will now require prior authorization. Cost share may vary based on place of service, type of procedure, and plan benefits.
|
Minimum allowable deductible
|
The IRS has determined that the minimum allowable deductible for HSA-qualified high deductible plans will be $1,700 (individual) and $3,400 (family) for 2026.
|
Out-of-pocket maximum
|
The IRS has determined that the out-of-pocket maximum for HSA-qualified high deductible plans can be no more than $8,500 (individual) and $17,000 (family) for 2026. The Department of Health and Human Services has determined that the out-of-pocket maximum for plans that are not high deductible can be no more than $10,150 (individual) and $20,300 (family) for 2026.
|
Mandated regulatory changes
|
Plan design changes have been made pursuant to state and federal requirements.
|
Plan design changes
|
The out-of-network allowed amount calculation for PPO and HDPPO plans has been revised based on geographic location and facility type. Medicare and other governmental programs exclusion updated to note that the benefit reduction based on what Medicare pays applies even if the member fails to enroll in Medicare or doesn’t pay their Medicare premium. Large group exceptions to this exclusion: eligibility for Medicare by reason of age, disability, and end-stage renal disease. All plans will have a single standard level of appeal for utilization review.
|