CurrentBaylor Scott & White Health PlanPolicy N/A

Biosimilars Preferred Program — Coverage Criteria

Defines preferred biosimilar products (adalimumab and ustekinumab biosimilars) on Baylor Scott & White Health Plan formularies, coverage stance versus reference biologics, and authorization/prior authorization expectations for prescribers and pharmacies.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyBiosimilars Preferred Program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes in this revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a new prior authorization for all new starts and renewals of biosimilar therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2reference biologic classes listed

$0/Rxmember OOP with assistance

excludedbrand coverage stance

new PA requiredprior auth requirement

Formulary Preference & Coverage Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

On the Group Value/Group Choice formulary, brand Stelara (ustekinumab) and brand Humira (adalimumab) are not the formulary-preferred options where biosimilars provide no significant clinical advantage. Specifically, brand Stelara is excluded from pharmacy coverage on the Group Value Commercial Formulary effective 08/01/2025 (and on the BSWHP HIM Formulary effective 01/01/2026) because it does not offer significant benefit over ustekinumab biosimilars. Similarly, the formulary listing for brand Humira is marked as a benefit exclusion on the Group Value/Group Choice formulary for 2026 (brand Humira may remain available on some benefits only for continuation of therapy for current users).

What Prescribers & Pharmacies Must Do

Prior Authorization

Prior Authorization Required

Existing reference brand approvals will be applied to all formulary biosimilars; however, all new starts and renewals will require a new prior authorization.

Note

Medical Benefit / Site Alignment

Yes. Preferred IV biosimilars should be prescribed for loading doses under the medical benefit. BSWHP typically aligns preferred products across medical and pharmacy benefits.

Denial Risk

Formulary Exclusion — Denial Risk

Brand Stelara is excluded from pharmacy coverage on the Group Value Commercial Formulary (effective 2025-08-01) and on the BSWHP HIM Formulary (effective 2026-01-01) since it does not offer significant benefit over ustekinumab biosimilars. Prescribing an excluded reference brand may result in claim denial.

Documentation Required

Prescribe Specific Biosimilar Product

Select the biosimilar best suited for your patient. If possible, include the 4-letter suffix when ordering unbranded products (for example, Adalimumab-aaty for unbranded Yuflyma) to prevent confusion and reduce clarification calls.

Key Terms & Substitution Practice

Interchangeable / substitution practice

Pharmacy substitution requirementAlthough some biosimilars (e.g., ustekinumab biosimilars) are interchangeable, the pharmacy requires the prescriber to specify which biosimilar product to substitute.

Prescribe specific product nameInclude the exact biosimilar product name on the prescription to indicate prescriber preference (prevents unintended substitution).

Include 4-letter suffix for unbranded productsWhen prescribing unbranded biosimilars, include the 4-letter suffix (e.g., Adalimumab-aaty) to avoid confusion and clarification calls.

Best practice for orderingSelect the biosimilar best suited for the patient and list it explicitly on the order to ensure the pharmacy dispenses the intended product.

New Start Authorization Requirements

New start authorization — prescribing and authorization for new starts

Prescribing and authorization for new starts

New starts: New biosimilar prescriptions require a new prior authorization; prescribers should specify the preferred biosimilar product on the prescription (include the 4-letter suffix for unbranded products when possible).

Existing brand approvals will be applied to formulary biosimilars when appropriate.

Continuation & Legacy Access

Continuation of therapy — continuation/legacy access notes

Continuation/legacy access notes

Continuation of therapy for current users: Some reference brand products may remain available only for continuation of therapy for current users (for example, Brand Humira and Brand Stelara may be excluded from pharmacy coverage on Group Value/Group Choice but remain available for continuation of therapy in specified benefits).

See formulary for specific benefit exceptions and effective dates.

Step	Requirement	Site of Care
1	Preferred IV biosimilars should be used for loading doses; prescribers must order the preferred IV biosimilar product for initial (loading) administration.	Medical benefit (infusion center) — IV loading doses should be prescribed and billed under the medical benefit.

Preferred Biosimilars & Effective Dates

Billing Rule

Humira coverage and preference (effective 01/01/2025)

Effective 01/01/2025, adalimumab biosimilars (Simlandi, Hadlima, Adalimumab-aaty/unbranded Yuflyma) are preferred on the Group Value/Group Choice and HIM formularies; Brand Humira is excluded on the Group Value/Group Choice formulary.

Note

Preferred adalimumab biosimilars effective 01/01/2025

Prescribe one of the preferred adalimumab biosimilars (Simlandi, Hadlima, Adalimumab-aaty/unbranded Yuflyma) for members on Group Value/Group Choice and HIM formularies beginning 01/01/2025.

Documentation Required

Include 4-letter suffix for unbranded adalimumab

When prescribing an unbranded adalimumab biosimilar (e.g., Yuflyma), include the 4-letter suffix (for example, Adalimumab-aaty) on the prescription.

Billing Rule

Stelara coverage and preference (effective 08/01/2025)

Effective 08/01/2025, ustekinumab biosimilars (Steqeyma, Selarsdi, Yesintek) are preferred on the Group Value/Group Choice and HIM formularies; Brand Stelara is excluded on the Group Value/Group Choice formulary (exclusion effective 8/1/2025).

Note

Preferred ustekinumab biosimilars effective 08/01/2025

For members on Group Value/Group Choice and HIM formularies starting 08/01/2025, prescribe one of the preferred ustekinumab biosimilars (Steqeyma, Selarsdi, Yesintek) rather than brand Stelara.

Step Therapy

Order preferred ustekinumab biosimilar to avoid coverage issues

Beginning 08/01/2025, order ustekinumab therapy using a preferred ustekinumab biosimilar listed on the formulary for Group Value/Group Choice and HIM benefits to avoid coverage issues.

Clinical Rationale

Biosimilars are recognized as safe and effective alternatives to their reference biologics that provide equivalent clinical indications at lower cost. For adalimumab and ustekinumab, biosimilars are approved for the same indications as the originator products; clinicians should consult each product’s prescribing information for up‑to‑date indication and pediatric guidance. When ordering, best practice is to specify the exact biosimilar product (including the 4‑letter suffix for unbranded products) to ensure correct dispensing and to support formulary-preferred use.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyBiosimilars Preferred Program — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes in this revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a new prior authorization for all new starts and renewals of biosimilar therapies.

SourceLink

On This Page

OpenPayer

Biosimilars Preferred Program — Coverage Criteria

Formulary Preference & Coverage Rules

What Prescribers & Pharmacies Must Do

Key Terms & Substitution Practice

New Start Authorization Requirements

Continuation & Legacy Access

Site of Care & Step Requirements

Infusion & Administration Guidance

Preferred Biosimilars & Effective Dates

Clinical Rationale