What Is A Formulary?

We’ve all seen the big marketing campaigns promoting new (and expensive) medications that offer improved results in treating a difficult medical condition. Health insurance plans have adopted a variety of strategies to manage costs while trying to provide adequate access to the most effective medicine options.

A health insurance company can manage its own pharmacy benefits or hire another company as its PBM (Pharmacy Benefit Manager). The health insurance company and the PBM agree to a “formulary” of medications that will be used. A formulary is a list of medications covered by an insurance plan. The medications are categorized by tier levels.

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Employers must comply with numerous reporting and disclosure requirements throughout the year in connection with their group health plans.

Listed below are upcoming important compliance deadlines for employer-sponsored group health plans, organized chronologically. For these requirements, the information provided herein shows the deadlines that apply to the calendar year plans. For non-calendar year plans, these deadlines will need to be adjusted to reflect each plan’s specific plan year.

February 2020

ALEs that sponsor fully or self-insured health plans are required to report information about the coverage to the IRS each year, using IRS Forms 1094-C and 1095-C. Employers that sponsor self-insured plans and are not ALEs use IRS Forms 1094-B and 1095-B to meet these reporting obligations. The deadline for filing paper versions of the forms is Feb. 28, 2020. The deadline for electronic filing is March 31, 2020.

March 2020

Group health plan sponsors that provide prescription drug coverage to Medicare Part D-eligible individuals must disclose to the Centers for Medicare & Medicaid Services (CMS) whether prescription drug coverage is creditable or non-creditable within 60 days after the beginning of the plan year. For calendar year plans, the deadline is March 1, 2020.

ALEs that sponsor fully or self-insured health plans to report information about the coverage to covered employees each year, using IRS Form 1095-C. Employers that are not ALEs use IRS Form 1095-B to provide this information. The IRS recently extended the deadline for furnishing 2019 employee statements, from Jan. 31, 2020, to March 2, 2020.

The electronic filing deadline for Code Sections 6055 and 6056 reporting is March 31, 2020. ALEs that sponsor fully or self-insured health plans are required to report information about the coverage to the IRS each year, using IRS Forms 1094-C and 1095-C. Employers that sponsor self-insured plans and are not ALEs use IRS Forms 1094-B and 1095-B to meet these reporting obligations.


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