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 plans, requiring standard inflammatory conditions prior authorization criteria and directing trials of all Preferred Products before approval of Non-Preferred Products; specifies documentation and NDC-based distinctions.

Policy Summary

PayerCigna

PolicyAdalimumab Products Preferred Specialty Management Policy for Legacy Drug List Plans

Policy CodePolicy PSM003

Change TypeSelected revisionsmaterial updates to preferred/non-preferred/non-covered lists

Effective DateMar 1, 2026

Next Review Date

Key ActionRequire standard Inflammatory Conditions prior authorization and document trials of Preferred Products and formulation-related contraindications when requesting Non-Preferred adalimumab products.

SourceLink

POLICY UPDATE CHANGES

New policy created (Summary of Changes = New policy).

Humira (NDCs starting with 83457) and certain other NDC-specific products were designated as benefit excluded (non-covered).

Preferred product and Non-Preferred product lists updated and adalimumab-adaz moved from Preferred to Non-Preferred.

Appendix A updated to add multiple Preferred Non-Adalimumab Products by indication (various biologics and small molecules).

3Preferred adalimumab product group members (by primary listed items)

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Non-Preferred adalimumab product group members

5Non-Covered adalimumab product entries (NDC-specific)

MultipleOther Preferred non-adalimumab products (Appendix A)

Coverage Summary

This policy defines Preferred, Non-Preferred, and Non-Covered adalimumab products for Cigna legacy drug list plans and requires that all adalimumab products meet the standard Inflammatory Conditions - Adalimumab Products prior authorization criteria. The program promotes use of Preferred Products and directs patients to try ALL Preferred Products before approval of a Non-Preferred Product; Non-Preferred approvals require meeting exception criteria including documented trials of Preferred Products. Coverage distinctions are enforced by product and specific NDC prefixes, and approvals are issued for the duration noted in the standard prior authorization policy.

General coverage and Prior Authorization

Covered when ALL of the following are met:

ALL of the following

Patient meets the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy criteria
For Non-Preferred Products, patient must meet the Non-Preferred Product Exception Criteria (see below) or trial Preferred Products as directed

Non-Preferred Product Exception Criteria

Non-Preferred Product Exception Criteria (for specified Non-Preferred adalimumab products)

Approve if the patient meets BOTH of the following (A and B):

A: Patient meets the standard Inflammatory Conditions - Adalimumab Products Prior Authorization Policy criteria

i: Patient has tried ALL of Cyltezo/adalimumab-adbm, Humira (NDCs starting with 00074), and Simlandi/adalimumab-ryvk (NDCs starting with 82009)
Documentation required; a trial of adalimumab-ryvk with NDCs starting with 51759 also counts. A trial of Humira with NDCs starting with 83457 also counts.
ii: Patient cannot continue to use ALL Preferred medications due to formulation differences in the inactive ingredient(s) which, according to the prescriber, would result in a significant allergy or serious adverse reaction
Documentation required. Documentation may include chart notes, prescription claims records, and/or prescription receipts and must include patient-specific identifying information.

Applicable Products and NDC-specific Coverage

Preferred ProductsNDC|mixedCovered

Cyltezo / adalimumab-adbm	Preferred product
Humira NDCs starting with 00074	Preferred product (specified NDC prefix)
Simlandi / adalimumab-ryvk NDCs starting with 82009	Preferred product (specified NDC prefix)

Non-Preferred Products (may be approved only if exception criteria met)NDC|mixed

Abrilada (adalimumab-afzb)	Non-Preferred
Amjevita NDCs starting with 72511	Non-Preferred (specified NDC prefix)
Hadlima (adalimumab-bwwd branded form)	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	Not covered on pharmacy and medical benefits for Employer Plans
adalimumab-ryvk NDCs starting with 51759	Not covered (NDC prefix specified); note counts toward trial for preferred -ryvk
Amjevita NDCs starting with 84612	Not covered (NDC prefix specified)
Humira NDCs starting with 83457	Not covered (NDC prefix specified); note counts toward trial for preferred Humira
Hyrimoz NDCs starting with 83457	Not covered (NDC prefix specified)

Other (Non-Adalimumab) Preferred Products by Indication (Appendix A)mixedCovered

Enbrel	Preferred for multiple rheumatology/dermatology/gastroenterology indications
Taltz	Preferred for certain indications
Cimzia	Preferred for nr-axSpA
Otezla / Otezla XR	Preferred for PsA and Psoriasis (Otezla XR added)
Skyrizi SC	Preferred in several indications
Ustekinumab SC products (Stelara SC, Selarsdi SC, Ustekinumab-ttwe SC, Yesintek SC)	Preferred options
Tremfya SC	Preferred non-adalimumab product for select indications
Cosentyx SC	Preferred for HS
Omvoh SC	Preferred for Crohn's disease and UC
Velsipity	Preferred (added) for some indications

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Coverage is enforced on an NDC-specific basis. For example, Humira with NDCs starting with 00074 is listed as a Preferred Product while Humira NDCs starting with 83457 are designated as Non-Covered; claims for Non-Covered NDC prefixes will be denied and may be redirected to Preferred Products. The policy notes certain NDC prefixes (e.g., adalimumab-ryvk NDCs starting with 51759 and Humira NDCs starting with 83457) may still count toward a required trial of the corresponding Preferred product when documenting trials.

Provider Actions & Billing Implications

Prior Authorization

Standard Prior Authorization required

All adalimumab products (both 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 standard prior authorization policy.

Documentation Required

Documentation of trials and formulation allergy required

When documentation is required, the prescriber must provide written, patient-specific documentation supporting trials of the Preferred Products and evidence that formulation differences in inactive ingredients would cause a significant allergy or serious adverse reaction. Acceptable documentation may include chart notes, prescription claims records, and prescription receipts.

Background

Background: Adalimumab and multiple biosimilars are indicated for various inflammatory conditions. Biosimilars were approved as demonstrating no clinically meaningful differences in safety and effectiveness compared with Humira, sharing mechanism of action, route, dosage form, and strength, although minor differences in clinically inactive components are allowed. The program promotes use of Preferred Products and requires the standard prior authorization for all adalimumab products.

Clinical Evidence

No formal trial or quantitative evidence entries are provided in the brief. The policy notes that biosimilars demonstrate no clinically meaningful differences in safety and effectiveness but may have minor formulation differences limited to inactive ingredients; such formulation differences are the basis for exception documentation when a patient cannot use Preferred Products. Do not include trial metric cards here as no trial metrics are supplied in the brief.

Revision History

11/01/2024policy_added

New policy created (Summary of Changes = New policy).

01/01/2025policy_revised

Selected revision: Cosentyx added to Appendix A as a Preferred Non-Adalimumab Product for hidradenitis suppurativa.

02/01/2025policy_revised

Selected revision: Velsipity added as a Preferred non-adalimumab product.

Policy Summary

PayerCigna

PolicyAdalimumab Products Preferred Specialty Management Policy for Legacy Drug List Plans

Policy CodePolicy PSM003

Change TypeSelected revisionsmaterial updates to preferred/non-preferred/non-covered lists

Effective DateMar 1, 2026

Next Review Date

SourceLink

On This Page

title':'Non-Preferred Product Exception Criteria (for specified Non-Preferred adalimumab products)'}]}

Definitions used in this policy: Preferred Products — adalimumab products designated by Cigna as preferred under this policy; trials of these are required prior to Non-Preferred approval. Non-Preferred Products — adalimumab products that require meeting exception criteria (including documented trials of all Preferred Products and formulation-related contraindication) for approval. Non-Covered Products — adalimumab products (specified by manufacturer and NDC prefixes) that are not covered on the pharmacy and medical benefits for Employer Plans.

Billing Rule

NDC-specific coverage enforcement

Coverage status (Preferred, Non-Preferred, or Non-Covered) is determined by product and specified NDC prefixes (examples: Humira NDCs starting with 00074 = Preferred; Humira NDCs starting with 83457 = Non-Covered). When billing, providers must use the most appropriate codes as of the submission date; claims submitted with codes not covered under the policy will be denied as not covered.

Denial Risk

Non-covered product claim denial

Products designated as Non-Covered (specific adalimumab products and NDC prefixes listed in the policy) are not approved on the pharmacy and medical benefits for Employer Plans; requests for those products will be denied and may be redirected to Preferred Products for review under the standard prior authorization criteria.

03/15/2025policy_revised

Selected revision: Omvoh added as a Preferred Non-Adalimumab Product for Crohn's disease and ulcerative colitis.

04/01/2025policy_revised

Selected revision: Appendix updated to add Selarsdi, ustekinumab-ttwe, and Yesintek subcutaneous as Preferred Non-Adalimumab Products for multiple indications.

04/15/2025policy_revised

Selected revision: Tremfya Subcutaneous added to Appendix A as a Preferred Non-Adalimumab Product for Crohn's disease.

05/15/2025policy_revised

Selected revision: Removed continuation allowance ('Patient is currently taking the requested adalimumab product for ≥ 120 days') for Non-Preferred products; adalimumab-adaz moved from Preferred to Non-Preferred and documentation requirement added to support formulation-difference exception; documentation required for formulation-related allergy/serious adverse reaction.

07/15/2025policy_revised

Selected revision: Patients currently taking adalimumab-adaz were temporarily allowed an exception to the preferred product requirement (later removed).

09/01/2025policy_revised

Annual/selected revision: Adalimumab-adaz continuation exception removed (continuation no longer an approval pathway); specified that NDCs starting with 82009 for adalimumab-ryvk are Preferred; Otezla XR added as Preferred for psoriatic arthritis and psoriasis.

01/01/2026policy_revised

Annual revision: Multiple adalimumab products and NDC-specific entries (adalimumab-bwwd, adalimumab-ryvk NDCs starting with 51759, Amjevita NDCs starting with 84612, Humira NDCs starting with 83457, Hyrimoz NDCs starting with 83457) were added as Non-Covered products and directed to Preferred Products; notes added that those NDCs count toward trials of preferred -ryvk and Humira.

03/01/2026policy_revisedLatest

Selected revisions through 03/01/2026 finalized policy effective date: policy effective 03/01/2026 with material changes including designation of Humira NDCs starting with 83457 (and other specified NDC prefixes) as benefit excluded (non-covered); updates to Preferred and Non-Preferred lists; added documentation requirements and removed continuation allowance for adalimumab-adaz.