Biosimilar for Stelara added to formularies

Blue Cross and Blue Shield of Kansas City (Blue KC) is committed to providing affordable and accessible healthcare for our members, which is why we are expanding our lower cost and FDA-approved biosimilar medications starting January 1, 2026.

Member plan documents have been updated to encourage the use of these cost-saving options. The plan documents state that a non-preferred^* biologic medication will not be covered in full under the plan if a preferred^* biosimilar medication is available.

Medication moving to excluded status

As of January 1, 2026, Stelara will move from preferred to excluded^** status. 

Penalty for using a non-preferred biologic medication

If a member uses a non-preferred biologic medication when a preferred biosimilar medication is available, the non-preferred member cost share indicated in the benefit schedule and the reference biologic product^*** penalty will apply: 

• The non-preferred member cost share indicated in the benefit schedule will accumulate toward the out-of-pocket maximum.
• The penalty will not accumulate toward the deductible and/or out-of-pocket maximum.

The penalty was implemented as of January 1, 2025, for any non-preferred biologic medication with a preferred biosimilar. Our pharmacy team will work closely with all stakeholders to ensure a smooth transition and mitigate any disruption to therapy.

Who the penalty applies to

The penalty generally applies to all members, with the following exceptions:

• Grandfathered (individual, small group, large group) products are excluded due to regulatory limitations.
• Small group transitional relief products are excluded due to regulatory limitations.
• Other exclusions include plans with no or limited Rx benefits, carve out PBM, Medicare Supplement, Joint Administrative Account (JAA), and Federal Employee Program (FEP).

Communications to members

Impacted members will receive a letter dated December 1 from Optum about their specific medication.

If you have questions about how Blue KC’s biosimilar product coverage impacts your clients, please contact your Blue KC representative. 

^*A preferred medication is one that Blue KC offers at a lower price on its formulary. A non-preferred medication is a more expensive option for the same medication on the same formulary.
^**An excluded medication is not on Blue KC formularies.
^***A biologic is often called a reference biologic product because it is the first to market.