CurrentCignaPolicy PSM003

Adalimumab Products Preferred Specialty Management Policy for Legacy Drug List Plans

Defines preferred, non-preferred, and non-covered adalimumab products for Cigna legacy drug list employer plans, requires meeting the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy criteria, and specifies exception criteria to approve non-preferred products after trials of all Preferred Products with required documentation. Also lists Non-Adalimumab preferred alternatives by indication (Appendix A).

Policy Summary

PayerCigna

PolicyAdalimumab Products Preferred Specialty Management Policy for Legacy Drug List Plans

Policy CodePolicy PSM003

Change TypeMultiple revisions since 11/01/2024 (product list updates, non-covered/ non-preferred adjustments)

Effective DateApr 15, 2026

Next Review Date

Key ActionFollow the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy and provide required documentation of trials of all Preferred Products when requesting Non-Preferred adalimumab products.

POLICY UPDATE CHANGES

New policy created 11/01/2024 and subsequently updated multiple times.

Selected revision 01/01/2025: Humira (NDCs starting with 83457) removed from policy (benefit excluded) and Hyrimoz requests directed to adalimumab-adaz.

Selected revision 05/15/2025: Removed 'Patient is currently taking the requested adalimumab product for ≥ 120 days' as approval option for non-preferred products; moved adalimumab-adaz to Non-Preferred.

Selected revision 03/01/2026: Added adalimumab-bwwd, adalimumab-ryvk (NDCs starting with 51759), Amjevita (NDCs starting with 84612), Humira (NDCs starting with 83457), Hyrimoz (NDCs starting with 83457) as Non-Covered products directing to Preferred Products.

Selected revision 04/15/2026: Imuldosa SC (NDCs starting with 69448) added as Preferred Ustekinumab SC product; Amjevita (NDCs starting with 55513) added as Non-Preferred product.

Coverage Summary

Defines Preferred Products, Non-Preferred Products, and Non-Covered Products for Cigna legacy drug list employer plans and requires that all requests meet the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy criteria. The program encourages use of Preferred Products and directs patients to try ALL Preferred Products before approval of a Non-Preferred Product; requests for Non-Preferred Products will be reviewed using the Non-Preferred Product Exception Criteria and require documentation where noted.

Non-Covered Products (specific product names and NDC blocks) are not approved on the pharmacy or medical benefits for Employer Plans; providers should refer to the customer's benefit plan document for covered products. Appendix A lists Non-Adalimumab preferred alternatives by indication to which patients may be referred.

Key definitions

Preferred ProductsAdalimumab products designated by Cigna as preferred for coverage under this policy: Cyltezo (adalimumab-adbm), Humira (NDCs starting with 00074), and Simlandi (adalimumab-ryvk; NDCs starting with 82009).

Non-Preferred ProductsAdalimumab products that require trial of ALL Preferred Products prior to approval and may be approved only with required exception documentation: Abrilada; Amjevita (NDCs starting with 55513 or 72511); Hadlima (adalimumab-bwwd); Hulio (adalimumab-fkjp); Hyrimoz (NDCs starting with 61314)/adalimumab-adaz; Idacio (adalimumab-aacf); Yuflyma (adalimumab-aaty); Yusimry. Requests reviewed using Non-Preferred Product Exception Criteria with documentation of trials and justification for formulation-related allergy or serious adverse reaction when applicable.

Non-Covered ProductsAdalimumab products not covered on pharmacy and medical benefits for Employer Plans: adalimumab-bwwd; adalimumab-ryvk (NDCs starting with 51759); Amjevita (NDCs starting with 84612); Humira (NDCs starting with 83457); Hyrimoz (NDCs starting with 83457). Refer to the customer's benefit plan document for covered products.

Coverage Criteria

Applicable Products / Codes

Preferred ProductsNDC|mixedCovered

Cyltezo / adalimumab-adbm	Preferred adalimumab biosimilar (preferred)
Humira (NDCs starting with 00074)	Preferred Humira NDC block specified
Simlandi / adalimumab-ryvk (NDCs starting with 82009)	Preferred -ryvk NDC block specified

Non-Preferred Products (requires trial of ALL Preferred Products; exception criteria apply)NDC|mixed

Abrilada	adalimumab-afzb (Pfizer)
Amjevita (NDCs starting with 55513 or 72511)	adalimumab-atto - Non-Preferred NDC blocks
Hadlima	adalimumab-bwwd branded (Organon/Samsung Bioepis) as Non-Preferred
Hulio / adalimumab-fkjp	Non-Preferred
Hyrimoz (NDCs starting with 61314) / adalimumab-adaz	Non-Preferred
Idacio / adalimumab-aacf	Non-Preferred
Yuflyma / adalimumab-aaty	Non-Preferred
Yusimry	adalimumab-aqvh Non-Preferred

Non-Covered ProductsNDC|mixedNot Covered

adalimumab-bwwd	Non-covered
adalimumab-ryvk (NDCs starting with 51759)	Non-covered NDC block
Amjevita (NDCs starting with 84612)	Non-covered NDC block
Humira (NDCs starting with 83457)	Non-covered NDC block
Hyrimoz (NDCs starting with 83457)	Non-covered NDC block

Non-Adalimumab Preferred Products (Appendix A) by indicationmixedCovered

Enbrel	Preferred for multiple rheumatologic indications
Taltz	Preferred for select indications
Cimzia	Preferred for nr-axSpA
Otezla / Otezla XR	Preferred for PsA/psoriasis (Otezla XR added)
Skyrizi SC	Preferred for multiple indications
Cosentyx SC	Preferred for Hidradenitis suppurativa (HS)
Omvoh SC	Preferred for Crohn's disease and Ulcerative Colitis
Ustekinumab SC products (Stelara SC, Imuldosa SC NDCs starting with 69448, Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC)	Preferred Ustekinumab SC products
Tremfya SC	Preferred for select GI indications (added to Appendix)
Velsipity	Preferred (added earlier)

1–10 of 11

1/2

mixed

No codes listed

Provider Actions & Prior Authorization

Prior Authorization

Standard prior authorization required

All products (Preferred and Non-Preferred) require meeting the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy criteria; approvals are provided for the duration noted in that prior authorization policy.

Prior Authorization

Trial of all Preferred Products required for Non-Preferred exceptions

To approve a Non-Preferred adalimumab, documentation must show trials of Cyltezo (adalimumab-adbm), Humira (NDCs starting with 00074), and Simlandi (adalimumab-ryvk, NDCs starting with 82009) unless prescriber documents inactive-ingredient formulation differences causing significant allergy or serious adverse reaction.

Cyltezo / adalimumab-adbm
Humira (NDCs starting with 00074)

Background

Adalimumab products are biosimilars/biologics indicated for multiple inflammatory conditions. Multiple biosimilar approvals indicate no clinically meaningful differences in safety and effectiveness versus Humira, with the same mechanism of action, route, dosage form, and strength. Minor differences in clinically inactive components are allowed and these formulation differences may affect tolerability.

The policy encourages the use of Preferred Products and allows exceptions when formulation differences in inactive ingredients, according to the prescriber, would result in a significant allergy or serious adverse reaction; documentation is required when such formulation-difference exceptions are claimed.

Clinical Evidence

No specific clinical trial metrics or evidence quantitative measures are provided in this policy brief. The biosimilarity statement and related considerations are summarized in the Background section.

Definitions

Preferred Products: Adalimumab products designated as preferred for coverage under this policy (Cyltezo/adalimumab-adbm; Humira NDCs starting with 00074; Simlandi/adalimumab-ryvk NDCs starting with 82009).

Non-Preferred Products: Adalimumab products that are directed to trial of ALL Preferred Products prior to approval; may be approved only when the Non-Preferred Product Exception Criteria are met and required documentation is provided.

Non-Covered Products: Adalimumab products (specific product names and NDC blocks) that are not covered on the pharmacy and medical benefits for Employer Plans.

Revision History

11/01/2024added

New policy created 11/01/2024 and subsequently updated multiple times.

01/01/2025revised

Selected revision 01/01/2025: Humira (NDCs starting with 83457) removed from policy (benefit excluded) and Hyrimoz requests directed to adalimumab-adaz.

05/15/2025revised