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Happy holidays to you!
As always, we appreciate your partnership and trust when it comes to serving our clients. We wish you good will over the holidays and good health and success in the New Year. This year, we’re pleased to donate to the Good Shepherd Food Bank on behalf of all of our brokers.
In this bulletin, we’ll provide information about our efforts to lower the total cost of care for your clients with our formulary, an emphasis on biosimilars and our enhanced infusion Site of Care program. We’ll also share reminders about new 2026 benefits and virtual primary care, our HMO tiered plan provider network and new 2026 Large Group plans. Finally, we’ll provide reminders about gag attestation requirements, upcoming events and Small Group attestation forms.
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Pharmacy launches new formulary on Jan. 1
Beginning Jan. 1, Community Health Options will offer two different versions of its formulary based on plan size. Members will need to choose the correct formulary from a drop-down menu to search for medications.
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Large Group and self-funded businesses will use the Incentive Formulary. This open formulary includes most FDA-approved medications, and Members will save on out-of-pocket costs by using generic medications and specific brand medications designated as preferred. Providers will need to submit Prior Approval requests for non-preferred products, which may be limited on quantity or have step therapy requirements. Prior Approval may also be required for preferred products.
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Small Group and Individual Members will have access to a Managed Formulary designed to lower costs for individuals/families and small businesses by including medications that are just as effective as expensive brands to reduce copays and overall spending for Members. As a result, it excludes multi-source brand name drugs and many non-preferred Tier 4 high-cost brands when there’s a comparable alternative. The formulary, which is consistent with industry standards, allows providers to ask for an exception for medical reasons.
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Biosimilars save money while offering effective treatment
Community Health Options encourages Members to use biosimilar medications instead of expensive biologic medications like Stelara or Humira that treat a range of conditions. These biosimilars offer the same treatments and health outcomes as brand names, but at much lower prices, reducing costs for Members and groups across our health plans. For example:
- Community Health Options has saved $2.2 million since transitioning Members from Humira to biosimilars beginning in July 2024. Note that Humira is no longer covered, effective July 1, 2025.
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In just three months, Community Health Options saved $1.4 million by moving Members from Stelara to biosimilars. Stelara won’t be covered, effective Jan. 1, 2026, unless approved under a benefits exception.
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Site of Care Infusion program incentive enhanced beginning Jan. 1
Community Health Options has expanded its unique voluntary Site of Care Infusion program. This program encourages Members to use convenient local infusion centers, giving them hassle-free care with flexible scheduling, often in a private room with amenities to help make the experience more comfortable.
Members who switch from a hospital to one of our approved local centers will receive an initial payment of $500 and subsequent payments of $50 after each treatment, up to a maximum lifetime benefit of $3,700 (Each year, Members receive a 1099 form per IRS guidelines.). The program has also expanded the number of drugs eligible for the program, from just 17 to more than 200 infused treatments. Members may also be eligible for treatment at home.
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Site of Care gives our health plans the potential to save money and has saved $8 million since 2019, ultimately leading to lower claims and reducing the total cost of care. Learn more here.
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New benefits available for Large Group and Merged Market
For Large Groups: New and continuing benefits include:
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Expanded $0 copay for virtual telehealth visits on all plans via Amwell, including HSA plans.
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Continued coverage through an Rx3 drug formulary that includes GLP-1 medications like Wegovy, Zepbound and Saxenda, along with other products for employers who choose to offer a weight loss benefit. Community Health Options’ benefit manager, Express Scripts, manages the medications through its Weight Value Program, which outlines specific coverage guidelines.
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A lowered emergency department copay to $250 from $350 for low-deductible Large Group plans (Cornerstone PPOs: $1000, $1500 and $2000).
For Small Groups: New and continuing benefits include:
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New advanced imaging site of service at specified locations, featuring a $250 copay for non-HSA Gold plans and a $350 copay for non-HSA Silver plans. HSA Gold and Silver plans have a copay after the deductible.
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Expanded $0 copay for virtual telehealth visits on all plans via Amwell, including HSA plans.
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Remember: All adult Members can access virtual primary care
All Members 18 and over can choose a primary care provider from Firefly Health, which offers 24/7 access to care, PCP and behavioral care access through a virtual care team, giving them care they need, anytime, anywhere. Each Member using the service gets a team that includes a doctor, nurse practitioner, behavioral health specialist and health guide. Through Firefly, Members can book appointments, chat online with a team, share symptoms and get referrals for in-person care with ease. Download a flyer for more information here.
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Understanding our tiered HMO health plan network
The provider network for our tiered HMO plans enables Members to save more on out-of-pocket costs without sacrificing choice, with preferred providers, including Maine Health primary care providers. These providers have a lower copay or coinsurance than standard providers.
Importantly, Members on HMO Tiered New England plans get access to Community Health Options full network, which includes hospitals in Maine, New Hampshire and most Centers of Excellence in Massachusetts. Importantly, we provide preferred inpatient and emergency care access to all Maine hospitals.
However, specialties and outpatient services may be designated as preferred or standard. In 2026, many outpatient hospital facilities and specialists continue to be designated as preferred, offering a lower copay or coinsurance than for a standard provider. Those include Maine Health Franklin Hospital, Lincoln Hospital, Pen Bay Hospital and Stephens Memorial. Many Maine Health specialty practices designated as preferred include cardiology, endocrinology, gastroenterology, OBGyn, ophthalmology, otolaryngology, podiatry and urology.
2026 plans will present in our provider directory beginning Jan. 1, 2026. Learn more here.
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Reminder: New Large Group plans available
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Community Health Options has also introduced three new Large Group PPO plans and one new HMO for 2026. These include:
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Cornerstone PPO $5500 30% $8000 RX1: This is the lowest cost National PPO because it has higher maximum out-of-pocket and does not offer a copay for emergency room visits. The plan will be a less expensive alternative to the Cornerstone PPO $6500 20% $7000 RX1 plan.
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Cornerstone PPO HSA Plus $4000 30% $6500 RX1: This lower-cost alternative to Cornerstone PPO HSA Plus $4000 20% $5500 RX1, has an AV similar to the other low-deductible HSA-eligible plans (Cornerstone PPO HSA Plus $3400 20% $6500 RX1). This new plan is intended to give a premium spread within the lower deductible PPO HSA-qualified plans.
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Cornerstone HMO National $7500 50% $9750 RX1D. This is the Lowest AV non-HSA plan and included pre-deductible copays for PCP, UC, PTOTST/Chiro, and Tiers 1-3 Rx. Specialist and Rx4-5 are after deductible.
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Cornerstone PPO $2000 30% $6000 RX1: This is a less expensive alternative to low-deductible PPO Nationals because of its higher maximum out-of-pocket levels and lack of an emergency room copay. This plan is intended to give premium spread for groups renewing or new clients shopping for a low-deductible plan. This will price similarly to the Cornerstone PPO $5000 20% $6000 RX1.
As a reminder, any Large Group with 65 or more employees and at least 100 plan Members can customize the cost-sharing designs of their plan.
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Meeting 2025 Gag Attestation requirements
The annual Gag Clause Prohibition Compliance Attestation is due by Dec. 31, 2025. Community Health Options is currently processing this filing for all fully insured plans.
Our attestation confirms that we have no contracts with providers, third-party administrators, or other service providers that contain prohibited "gag clauses" restricting the sharing of provider price, quality, or de-identified claims information. For self-insured clients, we can process your health plan’s filing, however, we need your approval. Please reach out to your account manager.
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Save the dates
2026 Broker Appreciation Event: The Business Development team is pleased to invite you to a Portland Sea Dogs game on Tuesday, June 2, 2026. The Sea Dogs are scheduled to play the Hartford Yard Goats at Hadlock Field in Portland. Keep an eye out for details.
Maine HR Convention: Join us at the Maine Society for Human Resource Management’s annual HR convention from May 4 to May 7, 2026, at the Samoset Resort. We’re proud to once again sponsor the SHRM event. You can register for the event here.
2026 Wellness Grants Cycle: Our 2026 grant cycle opens March 9, 2026, offering support to nonprofit organizations working to prevent diabetes and its complications. Please spread the word among organizations that promote healthy lifestyles and better health outcomes, so we can help make a difference. Applications must be submitted by April 10. Learn more about our 2025 recipients and our community giving program here.
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Process reminder: Small Group forms for new business and renewals
New Small Group Eligibility Attestation Forms: You can find eligibility attestation forms for new Small Group business on our website when you’re looking to write new business for a business with two or more eligible employees. Groups with 30 or more employees also need to complete a group verification form. Contact TJ Mcleod with questions about signing up a new group. Click here for the form.
Group Verification Forms, for renewals and new small groups with more than 30 employees: This form verified that your clients are still eligible for Small Group plans and should be submitted two to three months in advance of renewal. Contact your account manager with questions about renewals. Click here for the form.
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Community Health Options Resources
You can explore information tailored to your needs on Community Health Options’ website.
As always, you can find more detailed information on you broker resource pages once you login to the site, including marketing materials, a company profile or broker booklet, one-pagers with information on urgent care, dental services, our networks, chronic illness support and more.
If you have forgotten your broker portal password, it’s easy to reset it. Simply enter click on “forgot password?” and you’ll be asked three questions to confirm your identity. Once you do that, look for a confirmation email from noreply@healthoptions.org. If you don’t see the email in your inbox, check your junk folder. If you need help, call your account manager.
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If you have any questions, please send us an email. |
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