Currentblue cross blue shield - louisianaPolicy N/A

Humira Biosimilar Coverage Overview

Describes Louisiana Blue commercial formulary positioning, prior authorization expectations, preferred adalimumab biosimilars list and basic biosimilar attributes and substitution rules for Humira and its biosimilars for Louisiana Blue and HMO Louisiana commercial members.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyHumira Biosimilar Coverage Overview

Policy CodePolicy N/A

Change TypeInformational

Effective Date

Next Review Date

Key ActionSubmit a prior authorization request for all new adalimumab prescriptions for clinical review; existing approved authorizations for Humira cover switching to preferred biosimilars.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage or policy content.

PreferredFormulary status

Louisiana commercialScope

Interchangeable allowedSubstitution policy

Humira (adalimumab) biosimilar coverage overview

This overview applies to Louisiana Blue and HMO Louisiana commercial members and describes formulary positioning, prior authorization expectations, preferred adalimumab biosimilars, and basic biosimilar attributes and substitution rules for Humira and its biosimilars.

Humira (adalimumab) is preferred on all Louisiana Blue and HMO Louisiana commercial formularies. The guide highlights preferred biosimilar options (including product attributes such as concentration and citrate-free formulation), interchangeability status, and program details such as Quallent products being available at $0 out-of-pocket when filled through Accredo Specialty Pharmacy subject to copay program eligibility.

Prior authorization: All new adalimumab prescriptions require a prior authorization for clinical review. Members with an existing approved authorization for Humira do not need a new prior authorization to switch to any other preferred adalimumab product listed, and approved Humira authorizations apply to all preferred adalimumab biosimilars.

Key facts

Formulary statusPreferred on all commercial formularies

ScopeApplies to Louisiana Blue and HMO Louisiana commercial members

Substitution policyInterchangeable biosimilars may be substituted (pharmacist may substitute; Louisiana law requires patient consent and prescriber notification within 5 business days)

Policy statusCURRENT

Prior authorization and substitution rules

Prior Authorization Requirements

Prior authorization rules and switching notes for adalimumab products:

ALL of the following

All new adalimumab prescriptions require a prior authorization request for clinical review
Switching between preferred products
- Members with an approved authorization for Humira do not require a new prior authorization to switch to any other preferred adalimumab product listed
- Approved prior authorizations for Humira will apply to all preferred adalimumab biosimilars

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What providers and pharmacists must do

Prior Authorization

Prior authorization required for new prescriptions

Submit a prior authorization request for all new adalimumab prescriptions for clinical review; existing approved authorizations for Humira cover switching to preferred biosimilars. Members with an approved authorization for Humira do not require a new prior authorization to switch to any other preferred adalimumab product listed. Approved prior authorizations for Humira will apply to all preferred adalimumab biosimilars.

Documentation Required

Pharmacy substitution and notification (Louisiana law)

If an interchangeable biosimilar is substituted at the pharmacy, the pharmacist must obtain the patient's consent and notify the prescriber within 5 business days as required by Louisiana law.

Billing Rule

Zero out-of-pocket for Quallent via Accredo

Louisiana Blue and HMO Louisiana members will receive Quallent adalimumab products at $0 out-of-pocket when filled with Accredo Specialty Pharmacy, subject to Quallent Pharmaceuticals copay program eligibility requirements. Accredo Specialty Pharmacy is owned by Express Scripts.

Biosimilar definitions and formulation attributes

Biosimilars are biological products highly similar to an FDA-approved reference product with no clinically meaningful differences in safety, efficacy, purity, or potency.

Biosimilar: A biological product highly similar to an FDA-approved reference product with no clinically meaningful differences in safety, efficacy, purity and potency.

Interchangeable biosimilar: A biosimilar that meets additional requirements allowing pharmacy-level substitution for the reference product; Louisiana law requires the patient's consent and that the pharmacist notify the prescriber within 5 business days of the dispense date.