Biosimilar Medications

IMMEDIATE REQUIREMENTS: (1) Billing team must update billing software and formulary databases to reflect covered vs. non-covered biosimilar products listed in this policy. (2) For EACH of the 13 active ingredient categories listed (adalimumab, aflibercept, bevacizumab, denosumab, eculizumab, filgrastim, infliximab, natalizumab, pegfilgrastim, ranibizumab, rituximab, tocilizumab, trastuzumab, ustekinumab), verify member formulary coverage before adjudicating claims. (3) Configure system to DENY claims and services for non-covered products (e.g., Humira, Avastin, Prolia, Soliris, Xgeva, Rituxan, Herceptin, Stelara, etc.) with message directing to covered alternatives. (4) Staff processing prior authorizations must cross-reference member benefit plan language—this policy does not override individual member plan terms. DEADLINE FOR IMPLEMENTATION: Before the next claim submissions for these drug classes. CRITICAL DATE: Implement coverage termination for Prolia, Soliris, and Xgeva effective 08/15/2026—flag all active prescriptions for these medications now and begin member outreach 60 days before discontinuation date. CONSEQUENCE OF INACTION: Claims for non-covered biosimilars will be denied; claims for covered alternatives may be processed without appropriate verification.