Biosimilar for Stelara added to formularies starting January 1, 2026
Blue Cross and Blue Shield of Kansas City (Blue KC) aims to provide affordable and accessible healthcare for our members, which is why lower cost and FDA-approved biosimilar medications became available to members January 1, 2025.
To support this initiative of value improvement, we will be removing Stelara from our formulary effective January 1, 2026, and adding two lower-cost Stelara biosimilar options. This change will offer our members comparable therapy at a significantly reduced cost.
Effective January 1, 2026, a member may receive an exception to use Stelara instead of a biosimilar option on our formulary, however the member will be responsible for their standard cost share plus the difference in cost between Stelara and the preferred biosimilar. We are making efforts to ensure this additional cost share is a last resort.
As part of making biosimilars available to members, we are educating our brokers, prescribers, pharmacies, and individual members about this change. It is also important to share that we have selected biosimilar options that can be automatically substituted at the pharmacy.
Member plan documents have been updated to encourage the use of cost-saving biosimilar options. The plan documents state that a non-preferred* reference biologic medication will not be covered in full under the plan if a preferred* biosimilar medication is available.
We recognize the costs of specialty medications have been a strain on healthcare affordability. We appreciate your support in helping us deliver on our mission to improve our members’ health and the affordability of the healthcare they receive.
Biosimilar additional information
Medication moving to excluded status
On January 1, 2026, Stelara will move from preferred to excluded** status.
Penalty for using a non-preferred reference biologic medication
If a member uses a non-preferred reference 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.
This penalty was implemented January 1, 2025, for any non-preferred reference 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 November 30 from Blue KC about their specific medication.
Learn more about biological products
Please read Build a working knowledge of biological products to expand your understanding of biologic and biosimilar medications.
*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 type of medication on the same formulary.
**An excluded medication is not on Blue KC formularies.
*** A biologic is often called a reference biologic medication or reference biologic product because it is the first to market.
