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.<\/p>\n\n\n\n
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. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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\u2019 health and the affordability of the healthcare they receive.<\/p>\n\n\n\n
Medication moving to excluded status<\/strong> Penalty for using a non-preferred reference biologic medication<\/strong> 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.<\/p>\n\n\n\n Who the penalty applies to<\/strong> Impacted members will receive a letter dated November 30 from Blue KC about their specific medication.<\/p>\n\n\n\n
On January 1, 2026, Stelara will move from preferred to excluded** status.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n\n
The penalty generally applies to all members, with the following exceptions:<\/p>\n\n\n\n\n
Communications to members<\/strong><\/h2>\n\n\n\n
Learn more about biological products<\/strong><\/h2>\n\n\n\n