Biosimilars available to Blue KC members starting January 1, 2025
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 making lower cost and FDA-approved biosimilar medications available to members starting January 1, 2025.
To support this initiative of value improvement, we will be removing Humira from our formulary effective January 1, 2025, and adding three low-cost Humira biosimilar options. This change will offer our members comparable therapy at a significantly reduced cost.
Effective January 1, 2025, a member may receive an exception to use Humira instead of a biosimilar option on our formulary, however the member will be responsible for the majority of the medication cost. 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 will be updated to encourage the use of cost-saving biosimilar options. The plan documents will 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
As of January 1, 2025, Humira 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.
The penalty will be 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:
- Small group ACA will apply the penalty upon renewal. Small group ACA with a non-January 1, 2025, renewal date will enforce the penalty upon their 2025 renewal date.
- 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
These audiences will receive notifications about the availability and coverage of biosimilars:
- All enrollees – Late October letter
- Impacted members – November 30 letter from Optum 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.
