Cigna updated its MDC 09 (Dermatology & Plastic Surgery) adalimumab coverage to add biosimilars/unbranded products adalimumab-aaty (Yuflyma) and adalimumab-bwwd, stating they follow the same criteria as other subcutaneous adalimumab products and adding Q5140–Q5145 codes (effective 1/1/2025). The policy refines indication-specific initial and continuation rules: hidradenitis suppurativa initial approvals for 3 months (age ≥12, prior therapy trial, dermatologist involvement) with 1‑year continuation after ≥3 months of benefit; plaque psoriasis initial approvals for 3 months (age ≥18, trial of a traditional systemic agent or specified exceptions). Additional 2025 edits clarified ulcerative colitis initial-therapy language and added exceptions allowing prior trial or intolerance to another biologic, Otezla/Otezla XR, or Sotyktu to meet psoriasis step requirements. Continuation approvals across indications require objective improvement from baseline, and guideline references and an appendix place adalimumab among biologic and oral alternatives.
Selected Revisions: additions of `adalimumab-aaty` and `adalimumab-bwwd`, coding and indication clarifications
This selected revision set (most recent noted entries through 01/01/2026) documents additions and clarifications specific to adalimumab products in the Cigna Drug Coverage Policy IP0652 for MDC 09: Dermatology & Plastic Surgery (Skin/Breast). Notable entries in the revision history include the addition of the unbranded adalimumab product adalimumab-aaty (Yuflyma) and the product adalimumab-bwwd to the policy. The policy text explicitly states that "the same criteria apply as the other adalimumab subcutaneous products" for the added unbranded/biosimilar products.
Additionally, several earlier 2025 revisions refined indication-specific criteria: changes to initial therapy requirements for ulcerative colitis (removal of certain prior therapy options) and clarifications to plaque psoriasis initial-therapy exceptions (adding prior trial or intolerance to Otezla/Otezla XR or Sotyktu as an exception to the traditional systemic-agent requirement). The revision log also lists new HCPCS/CPT-like codes added effective 1/1/2025 (Q5140–Q5145), indicating updates to coding references used by the policy.
Coverage criteria for `hidradenitis suppurativa` and `plaque psoriasis` with initial and continuation pathways
The policy defines detailed, indication-specific coverage criteria for subcutaneous products across multiple dermatology and related indications, with explicit initial-therapy and continuation criteria. For the policy allows initial approval for 3 months when all three conditions are met: patient is ≥ 12 years old, has tried at least one other therapy (examples listed include intralesional/oral corticosteroids, systemic antibiotics, or isotretinoin), and the medication is prescribed by or in consultation with a dermatologist. Continuation (patients currently receiving an adalimumab product) may be approved for 1 year if the patient has been on therapy ≥ 3 months, demonstrates objective improvement by at least one measure, and reports symptomatic improvement (e.g., decreased pain or drainage).
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