Biosimilar preferred products list
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This document lists biosimilar products preferred by MedStar Family Choice District of Columbia for specified medical drug HCPCS codes and applicable places of service, effective November 1, 2025; it affects providers submitting medical drug claims to this payer in the District of Columbia.
MedStar Family Choice designates biosimilars as preferred for the products listed effective November 1, 2025.
Places of service to which the preference applies are specified: Office (11), On Campus Outpatient Hospital (22), Public Health Clinic (71), and Home (12).
Coverage Criteria
Preferred biosimilar coverage
Covered when using the payer-preferred biosimilar products listed
Preference applies effective November 1, 2025; applies to places of service: Office (11), On Campus Outpatient Hospital (22), Public Health Clinic (71), Home (12).
MedStar Family Choice designates the listed biosimilar products as preferred for the corresponding HCPCS codes when administered or billed in the covered places of service, effective November 1, 2025. Providers should use the payer-preferred biosimilar product/HCPCS combination shown in the table when requesting authorization or submitting claims (for example, Q5147 / Pavblu is preferred for aflibercept vs. the non-preferred Eylea (J0178)).
The policy lists preferred (column 2) and non-preferred (column 3) products for multiple biologic groups (e.g., VEGF inhibitors, TNF inhibitors, hematopoietic agents, anti-CD20 agents, IL-6/IL-23 antagonists, HER2 antagonists, RANKL inhibitors). Continuation of any existing authorizations for non-preferred products that were approved prior to November 1, 2025 will be honored.
This document does not identify any specific conditions, indications, or uses that are considered not medically necessary. The listing is an administrative preference for biosimilar products versus the named non-preferred reference biologics and does not revoke coverage based on clinical indication.
MedStar Family Choice explicitly states it will continue to cover existing approvals for non-preferred medical drug services that were authorized prior to November 1, 2025, so there is no automatic denial of previously authorized therapy based solely on the new preference list.
HCPCS / Product Coding
Provider Actions & Billing Guidance
Use preferred biosimilar HCPCS/product for prior authorization
Use the HCPCS codes and corresponding preferred biosimilar product names from the table when requesting authorization or submitting claims; reference the preferred product/HCPCS combination (biosimilar) rather than the non‑preferred reference biologic.
- Reference the HCPCS codes listed in column 1 and the preferred product name in column 2 of the table when requesting coverage.
- MedStar designated biosimilars as preferred effective November 1, 2025; cite the preferred HCPCS/product on authorization requests.
Biosimilar preferred‑first posture; no explicit step therapy
Policy communicates a preferred‑first posture for biosimilars versus the listed non‑preferred reference biologics but does not impose step‑therapy sequencing or require prior failure of the reference product.
- No explicit step‑therapy sequencing criteria or required failures are stated in the document.
- Providers should follow the biosimilar preference list but do not need to document trial-and-failure of the reference product per this policy.
Bill using the HCPCS code for the preferred biosimilar
Submit the HCPCS/medical drug code shown in the table for the administered product; when billing for a preferred biosimilar, use the biosimilar HCPCS code indicated in column 1 and list the preferred product name from column 2.
- Bill using the HCPCS code listed (column 1) that corresponds to the preferred biosimilar when that product is administered.
- Ensure the place of service and HCPCS match the table entry to reflect the payer’s preferred product.
Payer preference may affect claim payment
Claims for the listed products provided in the specified places of service may be adjudicated in favor of the biosimilar (preferred) product rather than the non‑preferred reference biologic.
- Preference applies to services delivered in Office (11), On Campus Outpatient Hospital (22), Public Health Clinic (71), and Home (12).
- Claims for non‑preferred reference products in those POS may be subject to payer preference for the biosimilar.
Background
Biosimilars are clinically similar alternatives to reference biologic therapies and are used across multiple therapeutic classes included in this list (for example, VEGF inhibitors, TNF inhibitors, hematopoietic agents, IL-6 and IL-23 antagonists, anti‑CD20 agents, HER2 antagonists, and RANKL inhibitors). This policy is administrative in scope: it identifies the payer-preferred biosimilar products and corresponding HCPCS codes to guide billing, prior authorization requests, and claim adjudication.
Key operational points: the preference applies in the specified places of service and becomes effective November 1, 2025. Providers should reference the preferred product name and HCPCS when seeking authorization or submitting claims to align with payer billing and payment practices.
Definitions
Continuation Criteria
Existing approvals continued
Continuation of existing authorizations
No disruption for pre-existing authorizations; applies regardless of the new preferred biosimilar list effective 11/01/2025.
Step Therapy / Prior Requirements
| Step | Requirement / Description |
|---|---|
| 1 | No explicit step therapy sequencing or required trial/failure of a reference biologic is specified. The policy establishes a preferred-first posture for listed biosimilars versus non-preferred reference biologics (effective Nov 1, 2025) and communicates the preferred biosimilar list for use when requesting authorization or submitting claims. |
Site-of-Care Applicability
Follow POS applicability for biosimilar preference
Preference applies when the service is performed in the listed places of service: Office (11), On Campus Outpatient Hospital (22), Public Health Clinic (71), and Home (12).
- Confirm the service POS code is one of: 11 (Office), 22 (On Campus Outpatient Hospital), 71 (Public Health Clinic), or 12 (Home).
- The biosimilar preference policy is operationally limited to these POS per the document.
Biosimilar Product Highlights
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