Does Anthem Cover Humira?
The verdict
Conditional on most plans
Anthem (Elevance Health) covers adalimumab, but the honest 2025–2026 answer is that branded Humira is increasingly displaced by adalimumab biosimilars on Anthem formularies via CarelonRx, consistent with the industry-wide shift. Across the big-three PBMs — CVS Caremark, Express Scripts, and OptumRx — branded Humira was removed from major commercial formularies in 2024–2025 in favor of private-label biosimilars, and CarelonRx-managed Anthem plans follow this pattern. Expect specialty-tier gating with prior authorization and step therapy often through the preferred biosimilar first. Verify the specific adalimumab product preferred on your Anthem/CarelonRx formulary.
Coverage is set by your specific plan and formulary. This is a research summary — always confirm with Anthem using your member ID.
Key facts
CVS Caremark removed branded Humira from major commercial formularies effective April 1, 2024; Express Scripts removed it for 2025; OptumRx excluded it effective January 2025 — CarelonRx (Anthem's PBM) follows the same market-wide biosimilar substitution direction.
CVS Health announcement Jan. 3, 2024; Express Scripts formulary updates 2025; OptumRx formulary update January 2025
More than 10 FDA-approved adalimumab biosimilars are now on the US market; the big-three PBMs have each selected a private-label or preferred biosimilar to displace branded Humira on standard commercial formularies.
FDA biosimilar product information; AbbVie company disclosures
The 2026 Medicare Part D out-of-pocket cap of $2,100 applies to adalimumab covered on the Part D specialty tier — once reached, the member pays $0 for covered Part D drugs for the remainder of the calendar year.
CMS 2026 Part D benefit parameters; Inflation Reduction Act
Medicare vs. commercial coverage
Whether Anthem covers Humira depends heavily on which kind of plan you hold. They follow completely different rules — here's each one, side by side.
Medicare
Part D & Advantage plans
Medicare Part D / Medicare Advantage: adalimumab is covered on the specialty tier (Tier 4/5) with prior authorization and step therapy via CarelonRx. Brand Humira and biosimilar preference depend on the specific Anthem MA-PD plan formulary — biosimilar adalimumab products are increasingly preferred in line with market trends. The $2,100 (2026) Part D out-of-pocket cap limits annual exposure; expect 25–33% specialty coinsurance after the deductible. Manufacturer copay assistance is NOT available to Medicare beneficiaries under federal anti-kickback rules. Verify the current formulary status of brand Humira versus biosimilar adalimumab on your specific Anthem Medicare plan.
Commercial / Employer
Group & marketplace plans
Commercial/Employer: adalimumab is on the specialty tier with PA and step therapy via CarelonRx; brand Humira is increasingly non-preferred as CarelonRx aligns with market-wide biosimilar substitution — verify on the CarelonRx formulary for your specific plan year. Commercially insured members may be eligible for manufacturer or biosimilar copay assistance programs — verify with AbbVie or the biosimilar manufacturer. ACA/Individual: adalimumab biosimilar preferred where offered; brand Humira likely non-preferred. Medicaid: Anthem-managed Medicaid covers adalimumab per state preferred drug list with PA; biosimilar preference per state PDL. Verify Anthem plan-specific coverage via CarelonRx formulary lookup.
The 3 boxes you must tick to get approved
Commercial plans that will consider Humira require prior authorization. Check off what applies to you to see how close you are — this is a guide, not a guarantee of approval.
Meet all 3 and you have a documented case for approval. Missing any one is the most common reason requests are denied.
Your cost, three ways
What Humira actually costs you swings enormously depending on how it's covered. Here's the realistic range.
Paying cash
Brand Humira list price is approximately $6,923 per 4-week supply (40 mg every other week; estimate per AbbVie). GoodRx estimate: approximately $6,749 for 2 pens. Adalimumab biosimilars (e.g., Hyrimoz, Amjevita) are listed well below brand Humira — estimate only.
List price with no coverage — before any manufacturer savings card.
With coverage
Commercial specialty tier: coinsurance typically 25–33% of the negotiated rate after deductible; actual dollar amount depends on the specific Anthem plan and the preferred adalimumab product's plan cost. Medicare Part D: 25–33% coinsurance capped by the $2,100 (2026) OOP cap. Commercially insured members may have access to manufacturer copay support or biosimilar copay assistance — verify eligibility. Medicaid: nominal cost-share per state PDL.
Typical monthly copay once prior authorization is approved.
Bridge program
AbbVie's myAbbVie Assist program and biosimilar manufacturer copay support may be available to commercially insured patients. Medicare and Medicaid beneficiaries are NOT eligible for manufacturer copay assistance. Verify eligibility directly with AbbVie or the biosimilar manufacturer.
Reduced copay through the assistance program, where eligible.
All figures are estimates. Actual cost-share depends on your specific Anthem plan, which adalimumab product is preferred, and plan-year formulary. Verify on CarelonRx formulary or by calling Anthem member services.
Check YOUR exact coverage in 3 steps
General answers only get you so far. Here's how to confirm your own plan's decision in a few minutes.
- 1
Look up adalimumab on the CarelonRx formulary for your Anthem plan
Visit carelonrx.com or log in to your Anthem member account and use the formulary search tool. Search for both 'Humira' and 'adalimumab' to see which product is preferred, what tier it is on, and whether PA and step therapy apply. Because CarelonRx aligns with industry biosimilar substitution trends, the preferred adalimumab product on your plan may be a biosimilar rather than branded Humira — confirm for your current plan year.
- 2
Have your prescriber submit prior authorization through CarelonRx
Your rheumatologist, gastroenterologist, or dermatologist submits the PA to CarelonRx on your behalf. Include the diagnosis, FDA-approved indication, relevant labs or clinical assessments, and documentation of any prior biologic or conventional DMARD trials. PA approval is typically 12 months and requires renewal. If branded Humira is requested but a preferred biosimilar is available, a medical exception or appeal may be needed.
- 3
Ask about biosimilar equivalents and copay assistance options
If your prescriber recommends adalimumab and the plan prefers a biosimilar over branded Humira, ask whether the preferred biosimilar is clinically appropriate for your indication. Adalimumab biosimilars approved by the FDA contain the same active ingredient and are generally considered therapeutically equivalent. Commercially insured patients may have access to copay support from the biosimilar manufacturer — verify before filling the first prescription.
Options if Anthem won't cover Humira
A denial isn't the end of the road. These are the paths people commonly explore next — discuss any of them with your prescriber.
Adalimumab biosimilar (Amjevita, Hyrimoz, Hadlima, or others)
Multiple FDA-approved adalimumab biosimilars are available; specific biosimilar preference depends on the CarelonRx formulary for your Anthem plan year. Biosimilars contain the same active ingredient and are generally therapeutically equivalent to branded Humira. Check your CarelonRx formulary for the preferred product.
Enbrel (etanercept)
TNF inhibitor biologic DMARD available as a preferred alternative for RA, PsA, and ankylosing spondylitis on some Anthem plans. No marketed biosimilar until 2029 (Erelzi/Eticovo blocked by patent litigation). Specialty tier with PA and step therapy — may be preferred over adalimumab on some Anthem formularies.
Orencia (abatacept)
T-cell costimulation modulator for RA and PsA, available as SC injection (pharmacy benefit) or IV infusion (medical benefit). Typically a second-line biologic option after TNF inhibitors. Specialty tier with PA and step therapy.
These options are listed for information only — your own clinician decides what is appropriate for you.
❓Frequently Asked Questions
Anthem covers adalimumab, but branded Humira is increasingly displaced by biosimilars on CarelonRx-managed formularies, consistent with the industry-wide shift — CVS Caremark removed branded Humira from major commercial formularies April 2024, Express Scripts removed it for 2025, and OptumRx excluded it effective January 2025. Anthem's CarelonRx follows this trend. Verify whether branded Humira or a specific biosimilar is preferred on your current Anthem plan by checking the CarelonRx formulary.
Anthem/CarelonRx typically requires prior authorization and step therapy for adalimumab. For RA and PsA, this often means documenting trial and failure of preferred biologic options — which may include an adalimumab biosimilar (as the preferred adalimumab product) and other preferred TNF inhibitors. Specific step-therapy sequences vary by indication. Your prescriber submits the PA with diagnosis and treatment history; approval is typically 12 months.
With Anthem commercial coverage, adalimumab is on the specialty tier with coinsurance typically 25–33% after the deductible. The exact dollar amount depends on your plan's negotiated rate for the preferred adalimumab product (brand or biosimilar). Commercially insured patients may be eligible for copay support from AbbVie or the biosimilar manufacturer, potentially reducing cost significantly. Verify your specific plan cost-share through CarelonRx and check copay assistance eligibility separately.
Anthem Medicare Advantage and Part D plans cover adalimumab on the specialty tier with PA and step therapy. Brand Humira versus biosimilar preference depends on your specific Anthem MA-PD plan formulary. The $2,100 (2026) Part D out-of-pocket cap applies once you reach that threshold for the year. Medicare beneficiaries cannot use AbbVie's manufacturer copay program — the Part D cap is the main cost protection.
FDA-approved adalimumab biosimilars contain the same active ingredient (adalimumab) and have been shown to have no clinically meaningful differences in safety or efficacy compared to branded Humira. Multiple biosimilars are available and approved across Humira's FDA-approved indications including RA, Crohn's, and psoriasis. Your prescriber can advise whether a specific biosimilar is appropriate for your indication; if you have concerns about a formulary switch, discuss options with your prescriber and Anthem.
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Read moreThis content is for informational purposes only and does not constitute medical, financial, or insurance advice. Coverage rules, prior-authorization criteria, and copay amounts change frequently and vary by plan, formulary tier, and effective date — always verify current benefits directly with Anthem before making any decision. Consult a licensed healthcare provider and your plan administrator for guidance specific to your situation.