By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Cigna in New York: 2025 Guide to Forms, Appeals, and Biosimilar Changes

Answer Box: Getting Humira Covered by Cigna in New York

Cigna removed brand Humira from most 2025 formularies, requiring step therapy through preferred biosimilars first. Three steps to coverage: (1) Try Cigna-preferred adalimumab biosimilars via Accredo specialty pharmacy at $0 copay, (2) If biosimilars fail, request formulary exception with detailed medical necessity documentation, (3) If denied, file New York DFS external review within 4 months—specialty drug appeals have 55-61% success rates. Start today: Contact your prescriber to document any prior adalimumab trials and check your current Cigna formulary status.

Table of Contents

  1. Coverage Basics: Is Humira Covered by Cigna?
  2. The Prior Authorization Process
  3. Timing and Urgency
  4. Medical Necessity Criteria
  5. Understanding Your Costs
  6. When Cigna Says No: Appeals in New York
  7. Renewal Requirements
  8. Specialty Pharmacy: Working with Accredo
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Humira Covered by Cigna?

Short answer: Brand Humira requires a formulary exception in 2025. Cigna has moved most commercial plans to prefer adalimumab biosimilars (Amjevita, Cyltezo, Hadlima) over brand Humira to manage costs as biosimilar competition increases.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all adalimumab products Cigna Provider Portal
Step Therapy Try 2+ preferred biosimilars first Cigna Formulary Exception Process
Specialty Pharmacy Dispensed through Accredo Cigna Specialty Pharmacy Guide
Lab Screening TB and Hepatitis B testing required FDA Humira Label

Which Cigna plans cover Humira? Most commercial Cigna plans include adalimumab products on formulary, but with step therapy requirements. Medicare Advantage plans may have different criteria—check your specific plan documents.

The Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Your prescriber initiates prior authorization through the Cigna Provider Portal or by fax
  2. Required documentation includes: diagnosis with ICD-10 code, specialist involvement, TB/Hepatitis B screening results, prior medication trials
  3. Cigna reviews within 15 business days (72 hours if expedited)
  4. If approved for biosimilar: Prescription transferred to Accredo specialty pharmacy
  5. If denied: Request peer-to-peer review immediately, then formal appeal if needed

Clinician Corner: Medical Necessity Letter Checklist

Healthcare providers should include these elements when requesting Humira coverage:

  • Clinical diagnosis with specific ICD-10 codes (e.g., M05.9 for rheumatoid arthritis)
  • Disease severity with objective measures (DAS28, CDAI scores, imaging results)
  • Prior therapy documentation with dates, dosages, duration, and specific outcomes
  • Contraindications or failures of preferred biosimilars with clinical details
  • Treatment goals and expected monitoring plan
  • Guideline references from ACR, AAD, or gastroenterology societies as appropriate

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies and medical criteria.

Timing and Urgency

Standard timeline: 15 business days for Cigna prior authorization decisions. Expedited review: 72 hours if your doctor certifies that standard timing could seriously jeopardize your health.

When to Request Expedited Review

  • Active disease flare requiring immediate treatment
  • Hospitalization risk without prompt therapy
  • Severe symptoms impacting daily functioning
  • Prior therapy discontinuation creating urgent need

How to expedite: Your prescriber calls Cigna at the number on your member ID card and requests expedited review with clinical justification.

Medical Necessity Criteria

Cigna's 2025 adalimumab coverage requires meeting specific clinical criteria based on your diagnosis:

Common Requirements Across Conditions

  • Specialist involvement (rheumatologist, dermatologist, gastroenterologist)
  • Tuberculosis screening within 12 months (TST or QuantiFERON-TB Gold)
  • Hepatitis B testing (verify with your plan's specific requirements)
  • Step therapy compliance through preferred biosimilars first
  • Documented treatment failures of conventional DMARDs or biologics

Condition-Specific Criteria

Rheumatoid Arthritis: Moderate to severe disease despite methotrexate or other conventional DMARD therapy

Crohn's Disease/Ulcerative Colitis: Moderate to severe disease with inadequate response to conventional therapy

Psoriasis: Body surface area involvement or PASI scores meeting severity thresholds

From Our Advocates: We've seen that appeals succeed most often when providers document not just what treatments were tried, but specifically why they failed—whether due to lack of efficacy measured by validated disease scores, intolerable side effects requiring discontinuation, or contraindications based on patient-specific factors. Generic statements like "patient failed methotrexate" are less persuasive than "patient discontinued methotrexate after 4 months due to persistent nausea and AST elevation to 89 U/L despite dose reduction."

Understanding Your Costs

Biosimilars vs. Brand Humira Costs

Preferred biosimilars through Accredo: Most patients pay $0 out-of-pocket with manufacturer copay assistance programs, regardless of insurance deductible or coinsurance.

Brand Humira (if approved via exception): Humira Complete offers up to $14,000 per calendar year in copay assistance for commercial insurance patients. You'll pay your plan's coinsurance minus the copay card benefit.

Cost Comparison Example

Scenario Monthly Cost Without Assistance With Manufacturer Assistance
Preferred Biosimilar $1,200-$1,500 $0
Brand Humira $6,000-$7,000 Varies (up to $14,000/year assistance)

Important: Copay assistance isn't available for Medicare, Medicaid, or other government insurance programs.

When Cigna Says No: Appeals in New York

New York offers robust appeal rights with multiple levels of review and strong success rates for well-documented specialty drug cases.

Internal Cigna Appeals

Timeline: File within 180 days of denial (New York extended this from the federal 60-day minimum)

Required documentation:

  • Patient information with Cigna member ID
  • Copy of denial letter with claim number
  • Medical necessity justification citing Cigna policies
  • Supporting clinical records
  • Specific relief requested
  • Physician signature

Submit to: Cigna National Appeals Unit, PO Box 188011, Chattanooga, TN 37422

Success rates: 70-78% overturn rate for medical necessity denials with comprehensive documentation

New York DFS External Review

If Cigna's internal appeal fails, New York State guarantees external review through the Department of Financial Services.

Key advantages:

  • Independent medical experts review your case
  • Decision is binding on Cigna
  • 55-61% success rate for specialty drug appeals
  • Expedited review available (72 hours for urgent cases)

How to file: Submit request within 4 months of final Cigna denial through the DFS Portal or by mail

Cost: Maximum $25 fee (waived for financial hardship or Medicaid enrollees)

Appeals Success Strategy

  1. Request peer-to-peer review immediately after denial—80-85% overturn rate for pre-authorization denials
  2. Cite specific Cigna policies and medical guidelines in your appeal
  3. Include objective clinical data (lab results, imaging, disease activity scores)
  4. Document biosimilar trials with specific dates, dosages, and outcomes
  5. Consider Counterforce Health for expert appeal assistance—they analyze denial letters and draft targeted rebuttals aligned to payer-specific requirements

Renewal Requirements

Humira prior authorizations typically require renewal every 12 months. Your prescriber will need to demonstrate:

  • Continued medical necessity with current clinical status
  • Treatment response documented through appropriate measures
  • Ongoing monitoring including required lab work
  • No new contraindications or safety concerns

Pro tip: Start renewal requests 30-60 days before expiration to avoid treatment gaps.

Specialty Pharmacy: Working with Accredo

Why Accredo? Cigna contracts with Accredo for most specialty medications, including adalimumab products. This isn't optional—it's required for coverage.

What to Expect

  1. Automatic transfer from your local pharmacy once approved
  2. Copay assistance coordination handled by Accredo pharmacists
  3. Home delivery with temperature-controlled shipping
  4. Clinical support including injection training and side effect monitoring
  5. Refill reminders and adherence support

Contact Accredo: Check your Cigna member portal for current contact information and to track shipments.

Troubleshooting Common Issues

Common Problems and Solutions

"Portal shows pending": Allow full 15 business days before following up unless urgent

"Missing lab results": Ensure TB and Hepatitis B screening uploaded to correct section

"Step therapy not documented": Provide specific dates, dosages, and outcomes of biosimilar trials

"Non-participating provider": Specialist may need to complete Cigna credentialing process

Technical issues: Call Cigna provider services at the number on your member card rather than relying on online portals during system outages

Frequently Asked Questions

How long does Cigna prior authorization take in New York? Standard review is 15 business days. Expedited review for urgent cases is completed within 72 hours if your doctor certifies medical urgency.

What if Humira is non-formulary on my plan? You'll need a formulary exception with clinical documentation showing medical necessity for brand Humira over preferred biosimilars.

Can I request an expedited appeal? Yes, if delaying treatment poses serious health risks. Your doctor must provide clinical justification for expedited processing.

Does step therapy apply if I failed biosimilars outside New York? Previous failures should count, but you'll need documentation from your prior providers showing specific trials, dates, and outcomes.

What's the difference between internal and external appeals? Internal appeals are reviewed by Cigna. External appeals in New York are reviewed by independent medical experts through the state DFS, with decisions binding on Cigna.

How much does the New York external appeal cost? Maximum $25 fee, waived for financial hardship or Medicaid enrollees. If you win, Cigna refunds the fee.

Can I continue current Humira during appeals? If you're already stable on Humira, request continuation of therapy during the appeal process. This isn't guaranteed but may be approved for medical continuity.

What if I'm switching from another state's insurance? New York's step therapy requirements still apply, but document any previous adalimumab trials to potentially expedite approval.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each payer's requirements, pulling appropriate evidence from FDA labeling, peer-reviewed studies, and specialty guidelines.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeal processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance appeals. Coverage policies and procedures may change—verify current requirements with Cigna and New York state regulators.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.