As a buy‑and‑bill specialty practice, you’re right at the epicenter of the unfolding Stelara (ustekinumab) biosimilar disruption.
At Remedy GPO, we’re watching these developments closely, and we’ve outlined here what you need to know now to stay ahead.
Biosimilars Flood the Market—PBMs Are Responding with Private Labels
As of July 2025, there are eight FDA-approved Stelara biosimilars on the U.S. market, all of which are fully interchangeable due to the expiration of Amgen’s exclusivity on Wezlana in April 2025.
These competitive products offer prices that range from 5% to 90% lower than the original Stelara brand.
To maintain market control and amplify margins, large PBMs have launched private‑label versions through their affiliated subsidiaries:
- Cordavis (CVS Caremark)
- Quallent Pharmaceuticals (Evernorth / Express Scripts / Cigna)
- Lumicera Health Services (Navitus / Optum Rx)
These private labels often serve as the preferred formulary option, even if other branded biosimilars or the reference Stelara itself remain technically available.
In addition, several smaller PBMs are embracing the Stelara shake-up; some, like MedImpact and CarelonRx, still include Stelara in their drug formularies.
Formulary Strategy: Private‑Label Preference Means Patient Flow Impacts You
Practices billing under medical benefit administration must track which version appears on payer formularies:
Express Scripts now prefers Quallent’s private‑label ustekinumab, pricing it only ~46% off Stelara, but has excluded both the brand and other biosimilars in many cases.
Optum Rx/Navitus removed Stelara entirely from their commercial and exchange formularies as of July 1, 2025, instead favoring its Lumicera private-label biosimilar (ustekinumab-aekn).
CVS Caremark, via Cordavis, is steering utilization toward its private-label Pyzchiva biosimilar with steep discounts compared to the reference Stelara.
That means your infusion therapy regimen, billing codes, and specialty drug purchasing decisions must align precisely with what the payer’s formulary and specialty pharmacy choice dictates.
Failure to do so at the point of care may result in coverage denials, retroactive reductions, or increased patient cost-share.
Financial Incentives & Hidden Rebates: What’s Really Going On
The shift toward private-label biosimilars isn’t just about lower prices; it’s also about how PBMs make money behind the scenes.
When a PBM promotes its private-label version of a drug (like through Cordavis or Quallent), it often earns extra hidden rebates and profits based on how much of that product is used.
This means that even if a private-label drug appears to be cheaper, its list price may be higher than that of other biosimilars.
The PBM makes up the difference by collecting undisclosed rebates from either the manufacturer or the insurance plan.
Therefore, for your practice, what matters most isn’t the sticker price; it’s whether the patient’s insurance plan will pay for the drug you administer.
Implications for Your Practice
Actionable steps you should take now:
- Review the formularies of the major payers with which you work. Confirm which Stelara variant (brand, branded biosimilar, private label) is covered, preferred, or excluded.
- Audit your documentation and coding workflows. Ensure that when private-label products like Quallent‑ustekinumab or Lumicera’s ustekinumab-aekn are in use, your billing reflects those specific NDCs or J‑codes.
- Communicate with your white‑label/specialty pharmacy partners. If the payer mandates a specific PBM-affiliated specialty pharmacy, coordinate patient transitions, prior authorizations, and copay assistance programs.
- Monitor patient cost-share. Most private‑label programs feature $0 copay assistance, but you’ll need to track this and explain it to patients, as traditional Stelara support programs may no longer apply.
- Track net contract pricing. Even if your practice acquires the product through your GPO or distributor, private‑label margins may affect reimbursement. Ensure contracts reflect real net costs for accounting and cost-of-goods forecasting.
The Role of Remedy GPO
At Remedy GPO, we’re committed to supporting your practice through this transition:
- We negotiate terms for branded and biosimilar Ustekinumab, including private‑label options, to help ensure your acquisition cost aligns with payer reimbursement.
- We provide support tools to crosswalk HCPCS/NDC codes, so your billing aligns with what payers expect.
- We monitor formulary changes, helping alert you when major payers revise coverage decisions affecting Stelara and its biosimilars.
In 2025, the Stelara market is being reshaped by aggressive PBM private‑label strategies, with formulary exclusion and preferential treatment of affiliated product subsidiaries now the norm. As a buy‑and‑bill practice, you must align your procurement, billing, and operations with these shifts, because what’s covered matters more than what’s prescribed.
Our goal is to help you navigate this new era of biosimilars with clarity and confidence, maximizing patient access while protecting your practice’s financial health. Because your ability to thrive through this Stelara shake‑up depends on how well you adapt, and we’re here in your corner.
