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Preferred Adalimumab Products (New)
Act
by Dec 15, 2025
Effective date
Jan 1, 2026
Identified
Jul 2, 2026
Summary
Humana has established a new Prior Authorization policy for preferred adalimumab products (Humira and biosimilars) effective January 1, 2026, across 10 clinical indications. The policy defines specific clinical criteria for approval based on diagnosis severity, age requirements, and prior therapy requirements that vary by indication. Billing teams must implement prior authorization verification before dispensing these medications or claims will be denied.
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What to do
by Dec 15, 2025 · 6 steps
01Billing and clinical teams must implement prior authorization requirements for all adalimumab products listed in this policy before the January 1, 2026 effective date.
02Update billing system and pharmacy software to trigger mandatory prior auth for J7303, J7304, J7305, and J7306 when billed for Medicare Advantage members.
03Configure system rules to verify member meets ALL applicable criteria for their specific indication (rheumatoid arthritis, juvenile idiopathic arthritis, plaque psoriasis, ankylosing spondylitis, Crohn's disease, psoriatic arthritis, ulcerative colitis, hidradenitis suppurativa, uveitis, or Behcet's disease oral ulcers).
04Create prior auth submission checklist in EMR/billing system requiring: diagnosis confirmation, age verification, and documentation of prior therapy/contraindication/intolerance per indication-specific requirements.
05Train pharmacy staff and billing team on indication-specific criteria (note: some indications require prior DMARD or NSAID therapy, others require age minimums ranging from 2-18 years).
06Establish appeal process for denials and communicate criteria to providers.
If missed: Failure to obtain and document prior authorization will result in claim denials from Humana Medicare Advantage plans.
Codes mentioned
J7303J7304J7305J7306
Original notice
Preferred Adalimumab Products (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Preferred Adalimumab Products (Revised)HighEffective Jan 1, 2026 · Medicare AdvantageNon-preferred adalimumab products (Revised)HighEffective Jan 1, 2026 · Medicare AdvantagePreferred Adalimumab Products (New)HighEffective Jan 1, 2026 · Medicare AdvantageNon-preferred adalimumab productsHighEffective Jan 1, 2026 · Medicare AdvantageBrowse every Humana change in the policy list