By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Cigna in California: 2025 Biosimilar Changes and Appeal Guide

Quick Answer: Getting Humira (adalimumab) Covered by Cigna in California

Starting in 2025, Cigna's Express Scripts has removed brand-name Humira from most commercial formularies, favoring biosimilar alternatives at $0 copay through Accredo. To get Humira covered, you'll need a formulary exception with clinical documentation showing biosimilar failure, adverse reactions, or contraindications. In California, if Cigna denies your request, you can file an Independent Medical Review (IMR) through the Department of Managed Health Care—a binding external review with high success rates for medically necessary treatments.

First step today: Have your doctor call Cigna at the number on your member card to request a formulary exception for Humira, documenting any prior biosimilar failures or medical reasons why alternatives won't work.

Table of Contents

When Biosimilar Alternatives Make Sense

Before pursuing brand-name Humira, consider whether Cigna's preferred adalimumab biosimilars could meet your needs. Clinical trials show equivalent efficacy and safety when switching from Humira to biosimilars like Cyltezo, Amjevita, or Hadlima, with no additional monitoring required beyond standard biologic therapy protocols.

Cigna's preferred biosimilars offer significant advantages:

  • $0 out-of-pocket cost through Accredo Specialty Pharmacy
  • Same active ingredient (adalimumab) as Humira
  • Citrate-free formulations may reduce injection site pain
  • No washout period needed when switching from Humira

However, you may need brand-name Humira if you've experienced:

  • Loss of disease control after switching to a biosimilar
  • Adverse reactions specific to biosimilar formulations
  • Immunogenicity (anti-drug antibody development)
  • Documented intolerance to biosimilar excipients

Cigna's 2025 Adalimumab Options

Product Manufacturer Cigna Status Patient Cost
Cyltezo Boehringer Ingelheim Preferred (interchangeable) $0 copay
Simlandi Teva Preferred (interchangeable) $0 copay
Adalimumab-adaz Sandoz Preferred $0 copay
Humira AbbVie Non-formulary Requires exception

Source: Express Scripts 2025 formulary changes

Step-by-Step: Fastest Path to Humira Approval

1. Gather Required Documentation (Patient/Clinic)

Collect your complete treatment history, including:

  • Previous adalimumab biosimilar trials with dates and outcomes
  • Documentation of adverse events or loss of efficacy
  • Current disease activity scores or clinical assessments
  • Lab results showing immunogenicity (if applicable)

2. Physician Submits Formulary Exception (Clinic)

Your doctor must call Cigna or complete the formulary exception form with detailed clinical justification.

Timeline: 2-3 business days for standard review, 24 hours for expedited requests

3. Appeal if Denied (Patient/Clinic)

If the initial request is denied, file an internal appeal with additional supporting evidence within 180 days of the denial.

4. Request California IMR (Patient)

After internal appeal denial, California residents can request an Independent Medical Review through the DMHC Help Center (888-466-2219).

Timeline: 45 days for standard IMR, 72 hours for expedited urgent cases

Medical Necessity Documentation

Clinician Corner: Essential Letter Components

When requesting a Humira formulary exception, your physician's letter must include:

Clinical History:

  • Specific dates and durations of previous biosimilar trials
  • Objective measures of treatment failure (disease activity scores, lab values)
  • Documentation of adverse events with biosimilars

Medical Necessity Statement:

  • Clear explanation why biosimilars are contraindicated or ineffective
  • Reference to FDA labeling and clinical guidelines supporting Humira use
  • Patient's current clinical status and treatment goals

Supporting Evidence:

  • Recent office visit notes and clinical assessments
  • Laboratory results (anti-drug antibodies if tested)
  • Specialist consultation notes if applicable
Tip: Include language that mirrors Cigna's coverage criteria, such as "lack of efficacy," "adverse event," or "medical contraindication" to align with their decision-making framework.

California Appeals Process

California offers robust patient protections through two regulatory agencies:

Department of Managed Health Care (DMHC) - Most Plans

  • Covers: HMOs and most PPO plans
  • Process: File grievance with health plan first, then request IMR
  • Timeline: 30 days for internal grievance, 45 days for IMR
  • Success Rate: High for medically necessary treatments with proper documentation

California Department of Insurance (CDI) - Some PPO Plans

  • Covers: Certain PPO and indemnity plans
  • Process: Similar external review process
  • Contact: CDI Consumer Hotline (800-927-4357)

California's IMR is binding - if the independent medical experts determine Humira is medically necessary, Cigna must authorize coverage.

Switching Back from Biosimilars

If you're currently on a biosimilar and experiencing problems, document everything carefully:

Required Documentation for Switch-Back Appeal:

  • Timeline: Dates of Humira discontinuation and biosimilar start
  • Clinical Evidence: Objective measures showing disease worsening
  • Laboratory Data: Anti-drug antibody tests if immunogenicity suspected
  • Adverse Events: Detailed records of side effects not present on Humira

Important: About 13% of patients switch back to Humira after trying biosimilars, often within 30 days. However, insurance approval requires strong clinical evidence, as studies show equivalent outcomes between Humira and biosimilars in most patients.

Cost-Saving Options

If Humira is Approved:

  • AbbVie Humira Complete: Patient support program offering copay assistance
  • Eligibility: Commercial insurance patients (not Medicare/Medicaid)
  • Savings: Up to $5 per injection with qualifying insurance

Alternative Support:

  • Patient Access Network Foundation: Grants for specialty medications
  • HealthWell Foundation: Financial assistance for eligible patients
  • California state programs: Check Covered California for additional resources

FAQ

How long does Cigna prior authorization take in California? Standard requests: 2-3 business days. Expedited requests for urgent medical situations: 24 hours. California law requires insurers to meet these timelines.

What if Humira is completely non-formulary on my plan? You can still request a formulary exception with clinical documentation. If denied, California's IMR process provides an independent medical review that's binding on the insurer.

Can I request expedited review? Yes, if your condition "seriously jeopardizes life, health, or ability to regain maximum function." Your doctor must document the urgency in the request.

Does step therapy apply if I tried biosimilars outside California? Yes, document all prior adalimumab trials regardless of location. Cigna will consider your complete treatment history when reviewing exception requests.

What happens if I'm denied at every level? California's IMR is the final binding decision. If approved through IMR, Cigna must provide coverage. Additional legal options may be available through patient advocacy organizations.

How much does Humira cost without insurance? List price is approximately $6,000-$7,000 per month. AbbVie's patient assistance programs may help eligible patients access the medication at reduced cost.

When navigating insurance coverage for specialty medications like Humira, having the right documentation and understanding your state-specific rights makes all the difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals that align with each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms, medical circumstances, and state regulations. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with California insurance complaints or appeals, contact the DMHC Help Center at 888-466-2219.

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