Humira Biosimilar Coverage and Pharmacy Program Updates
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Describes Care Continuum's coverage approach and formulary/prior-authorization updates related to Humira and its biosimilars for Commercial, Medicare, and Healthcare Exchange lines of business; intended for provider and pharmacy staff.
Amgen's Amjevita (Humira biosimilar) launched with two WAC pricing strategies (high WAC tied to rebates and low WAC without rebates) and Network Health will cover both versions for Commercial and Medicare.
Formulary tiers and PA/step therapy placement for Humira and Amjevita were specified by line of business (Commercial, Medicare, Healthcare Exchange).
Multiple prior authorization policy updates and new PAs were added or revised across numerous drugs (PAR-276 through PAR-657).
Coverage and Utilization Management by Line of Business
Line-of-Business Coverage
Coverage and utilization management by line of business
Provider Actions, Prior Authorization, and Step Therapy
Prior Authorization required for Humira/Amjevita (PA parity and PA updates)
Humira and Amjevita require prior authorization in applicable lines of business; this update notes PA parity for Amjevita and lists multiple PA policy updates across PAR-276 through PAR-657.
- Commercial: Humira — Tier 4 with Humira PA; Amjevita — Tier 4 with Humira PA (criteria at parity).
- Healthcare Exchange: Humira — Tier 4 with Humira PA; Amjevita — Tier 4 with Step Therapy.
- Medicare: Humira — Tier 5 with Humira PA; Amjevita — Tier 5 with Humira PA (criteria at parity).
- Multiple prior authorization policies were added or revised (PAR-276 through PAR-657).
Step therapy placement for Amjevita (Healthcare Exchange)
Amjevita is placed on step therapy in the Healthcare Exchange line of business while Humira is managed via prior authorization; step therapy applicability depends on the member's line of business.
- Healthcare Exchange: Amjevita — Tier 4 with Step Therapy; Humira — Tier 4 with Humira PA.
- Commercial and Medicare treat Amjevita with PA parity to Humira (no step therapy listed).
PA criteria alignment — follow Humira prior authorization criteria
Prescribers must follow the existing Humira prior authorization criteria; Amjevita's criteria are specified as being at parity with Humira for Commercial and Medicare lines of business.
- Amjevita coverage aligns with Humira criteria for Commercial and Medicare (criteria at parity).
- For clinical indications, Amjevita follows Humira's medically accepted indications per the prior authorization criteria.
Denial risk — obtain prior authorization for Humira/Amjevita when required
Failure to obtain required prior authorization for Humira or Amjevita in lines that list PA (Commercial and Medicare) may result in coverage denial; providers should obtain PA before dispensing or billing when applicable.
- Commercial and Medicare list Humira and Amjevita as requiring PA (Amjevita at parity with Humira) — obtain PA prior to treatment to avoid denial.
- Operational note: multiple PA policies were updated (PAR-276 through PAR-657) which may affect authorization processes.
Step Therapy Placement and Rules
| Line of Business | Humira (adalimumab) Coverage | Amjevita (adalimumab‑atto) Coverage |
|---|---|---|
| Commercial | Tier 4 (Preferred specialty) with Humira prior authorization (PA) | Tier 4 (Preferred specialty) with Humira prior authorization (PA); criteria at parity with Humira |
| Healthcare Exchange | Tier 4 (Preferred specialty) with Humira prior authorization (PA) | Tier 4 (Preferred specialty) with Step Therapy |
| Medicare | Tier 5 (Specialty) with Humira prior authorization (PA) | Tier 5 (Specialty) with Humira prior authorization (PA); criteria at parity with Humira |
Humira (Adalimumab) and Biosimilar Coverage
Network Health covers Humira and Amjevita; parity varies by line
Network Health covers both Humira and Amjevita across lines of business; Amjevita’s formulary placement and PA/step therapy parity with Humira vary by line (Commercial and Medicare parity; Healthcare Exchange may apply step therapy).
- Commercial: Both covered as Tier 4 (Preferred specialty) with Humira PA for both (criteria at parity).
- Healthcare Exchange: Humira covered with Humira PA; Amjevita covered with Step Therapy.
- Medicare: Both covered as Tier 5 (Specialty) with Humira PA for both (criteria at parity).
Key Definitions
Background and Market Context
Biosimilars to adalimumab began entering the U.S. market in early 2023 with Amgen's Amjevita launching in Q1 2023. Amjevita was introduced using two distinct wholesale acquisition cost (WAC) strategies: a high WAC version priced at 5% below Humira's list price and tied to rebates, and a low WAC version priced at 55% below Humira's list price with no rebates. Limited supply of the low WAC product was expected initially, with supply increases anticipated in the second half of 2023.
Care partners and payer programs adapted to these market dynamics by covering both WAC tiers for Commercial and Medicare lines of business. The manufacturer assistance program SaveOnSP will add Amjevita to its product mix while continuing to include Humira; updates to SaveOnSP drug lists remain subject to change. The dual high/low WAC launch strategy may influence how other manufacturers price future adalimumab biosimilars as they enter the market later in 2023.
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