Medicare AdvantagePrior AuthHigh impact
Non-preferred adalimumab products (Revised)
Humana·Rheumatology, Gastroenterology, Dermatology +1 more·Medicare Advantage
Effective date
Jan 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage is designating multiple adalimumab biosimilar products (Hadlima, Cyltezo, Hyrimoz, Yuflyma, Amjevita, Idacio, Abrilada, Simlandi, and others) as non-preferred, requiring prior authorization for eight indications. Patients must fail two prior treatments with preferred adalimumab products (Humira, adalimumab-adbm, or adalimumab-adaz) or specified alternative biologics before non-preferred products are covered.
Action Required
By January 1, 2026 (already effective): Billing and clinical teams must implement prior authorization requirements in the billing system for all non-preferred adalimumab products listed in this policy. For Medicare Advantage members requesting any of the following products—Hadlima, Cyltezo, Hyrimoz, Yuflyma, Amjevita, Idacio, Abrilada, Simlandi, adalimumab-ryvk, adalimumab-aacf, adalimumab-aaty, adalimumab-fkjp, or adalimumab-bwwd (across all formulations)—staff must verify the member meets ALL criteria for their diagnosis before claim submission. Specific requirements vary by indication: (1) Rheumatoid Arthritis, JIA, Plaque Psoriasis, Ankylosing Spondylitis, Psoriatic Arthritis, Crohn's Disease, and Ulcerative Colitis require documented failure of TWO prior treatments from a specified list; (2) Hidradenitis Suppurativa requires failure of preferred adalimumab AND Cosentyx SQ; (3) age restrictions apply per indication (18+, 12+, 6+, or 5+ depending on diagnosis). Providers must submit prior authorization requests with clinical documentation demonstrating treatment failure. Update encounter forms and EHR templates to include checkboxes for prior treatment history. Flag any claims for non-preferred adalimumab products submitted without prior authorization documentation—these will be denied by Humana. Revisions effective June 24, 2026 should be reviewed before that date to ensure no additional changes to criteria.