As specialty medications continue to represent a growing share of healthcare spending, policymakers, health plans and employers are increasingly looking to biosimilars as one of the most promising opportunities to improve affordability.

At Prime Therapeutics (Prime), the Medicare Center of Excellence team is built to serve as both a strategic advisor and operational partner for health plans and the Medicare patients they serve. That alignment shapes how the team works: looking across clinical, regulatory and cost considerations to find solutions that improve costs, access and health outcomes. So, when the team reviewed updated Centers for Medicare & Medicaid Services (CMS) guidance on biosimilars last year, they saw an opportunity that others might have missed.

Medicare’s fall 2025 guidance generally restricted biosimilar substitutions but did not clearly address Stelara biosimilars — biologic drugs used primarily to treat autoimmune conditions — which were made available after Medicare plans had submitted their formularies.

Understanding that the substitution of Stelara biosimilars could help lower costs without limiting clinically appropriate treatment options, the Center of Excellence team proposed CMS allow the substitution of Stelara biosimilars. CMS subsequently approved this substitution.

“We have deep expertise in navigating and interpreting CMS guidance, so we were confident they would approve our proposal, and what came next exceeded our expectations,” said Paul Glynn, Prime’s senior director of clinical account management.

With this change in effect, Prime estimates that the Medicare plans it serves will save nearly $27 million in 2026 from the Stelara substitution alone. 

“Prime played a leading role in helping to enact this change last year, recognizing it as an opportunity to clarify complexity within the system to deliver a solution that can lead to significant savings,” Glynn said. "Our Medicare team is highly specialized in helping clients navigate complexity, stay ahead of change and deliver greater value for their members.”

The opportunity emerged at a time when biosimilar adoption has become a major focus in healthcare, with biosimilars introducing competition into the market and helping lower costs, while maintaining clinically appropriate treatment options for patients. 

With the 2026 Medicare enrollment season in full swing, Prime continues to demonstrate other ways the organization stands apart to deliver better outcomes for Medicare plans. 

The Medicare Center of Excellence team hosted the annual Prime Stars & Bid Forum this month to meet with Medicare plan sponsors to discuss the trends shaping the future of healthcare. 

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