Does UnitedHealthcare Cover Humira?
The verdict
Conditional on most plans
UnitedHealthcare covers adalimumab, but the defining 2025–2026 fact is that OptumRx — UHC's pharmacy benefit manager — excluded branded Humira from commercial formularies effective January 2025, in favor of Amgen's Amjevita adalimumab biosimilar, including the Nuvaila private-label version. On some formularies (OptumRx Select Standard), branded Humira remains on Tier 3 with prior authorization as an exception pathway. For Medicare members, adalimumab is covered on the specialty tier with PA and step therapy; the $2,100 (2026) Part D out-of-pocket cap limits annual exposure. Verify your specific UHC plan formulary via OptumRx.
Coverage is set by your specific plan and formulary. This is a research summary — always confirm with UnitedHealthcare using your member ID.
Key facts
OptumRx (UHC's PBM) excluded branded Humira from commercial formularies effective January 2025, naming Amgen's Amjevita — including the Nuvaila private-label — as the preferred adalimumab product. Brand Humira may still be accessible on Tier 3 on OptumRx Select Standard formularies with PA.
OptumRx formulary update January 2025; Amgen Amjevita product information
CVS Caremark, Express Scripts, and OptumRx have all excluded brand Humira from their largest standard commercial formularies for 2024–2025, each designating a private-label adalimumab biosimilar as preferred.
CVS Health announcement Jan. 3, 2024; Express Scripts 2025 formulary exclusion list; OptumRx January 2025 formulary update
The 2026 Medicare Part D out-of-pocket cap of $2,100 applies to adalimumab covered on the specialty tier — once reached, the member pays $0 for covered Part D drugs for the rest of the calendar year.
CMS 2026 Part D benefit parameters; Inflation Reduction Act
Medicare vs. commercial coverage
Whether UnitedHealthcare 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 with prior authorization and step therapy via OptumRx. The specific preferred adalimumab product (brand Humira vs. Amjevita/Nuvaila biosimilar) depends on the specific UHC MA-PD or Part D plan formulary — biosimilar preference is increasing in line with the January 2025 commercial exclusion. The $2,100 (2026) Part D out-of-pocket cap limits annual exposure; expect 25–33% specialty coinsurance after the deductible until the cap is reached. Manufacturer copay assistance is NOT available to Medicare beneficiaries under federal anti-kickback rules. OptumRx specialty pharmacy is the required dispensing channel for most UHC plans.
Commercial / Employer
Group & marketplace plans
Commercial/Employer: OptumRx excluded branded Humira from standard commercial formularies effective January 2025, favoring Amjevita (adalimumab-atto) including the Nuvaila private-label product. Some formularies (OptumRx Select Standard) retain branded Humira on Tier 3 with prior authorization as an exception option. Specialty tier with PA and step therapy applies regardless of which adalimumab product is preferred. ACA/Individual: adalimumab biosimilar preferred; brand Humira likely excluded or non-preferred. Medicaid: UHC Community Plan covers adalimumab per state PDL with PA; biosimilar preference per state PDL. Commercially insured members may be eligible for biosimilar manufacturer copay assistance — verify before filling.
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. Amjevita and other adalimumab biosimilars are listed significantly below brand Humira — estimate only.
List price with no coverage — before any manufacturer savings card.
With coverage
Commercial specialty tier: 25–33% coinsurance after the deductible for the preferred biosimilar; actual dollar amount depends on the specific UHC plan's negotiated rate. If brand Humira is approved on Tier 3 (OptumRx Select Standard), the coinsurance may be higher. Medicare Part D: 25–33% coinsurance capped by the $2,100 (2026) OOP cap. Commercially insured members may have access to Amgen's Amjevita copay assistance or AbbVie's myAbbVie Assist — verify eligibility before filling.
Typical monthly copay once prior authorization is approved.
Bridge program
Amgen offers copay assistance for Amjevita; AbbVie offers myAbbVie Assist for brand Humira. Both are for commercially insured patients only — Medicare and Medicaid beneficiaries are NOT eligible under federal anti-kickback rules. Verify eligibility and program details directly with the manufacturer.
Reduced copay through the assistance program, where eligible.
All figures are estimates. Actual cost-share depends on your specific UHC plan formulary and which adalimumab product is preferred. Verify through OptumRx or by calling UHC member services at the number on your ID card.
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
Check your UHC formulary via OptumRx to confirm the preferred adalimumab product
Log in to your UHC member account at myuhc.com or visit optumrx.com and use the formulary search. Search for both 'Humira' and 'Amjevita' (and 'Nuvaila') to see which is listed, at what tier, and what PA and step-therapy requirements apply. For most standard UHC commercial plans as of January 2025, branded Humira is excluded in favor of Amjevita/Nuvaila. If you are on an OptumRx Select Standard formulary, confirm whether Humira Tier 3 access is available on your specific plan.
- 2
Have your prescriber submit PA through OptumRx for your specific adalimumab product
Your rheumatologist, gastroenterologist, or dermatologist submits the PA to OptumRx. Include the FDA-approved indication, relevant diagnostic documentation, and any prior biologic or conventional DMARD trial history. If brand Humira is medically necessary (e.g., due to the Nuvaila/Amjevita formulation), your prescriber must document the clinical justification. PA approval is typically 12 months and requires renewal.
- 3
Ask about Amjevita/biosimilar copay assistance if commercially insured
If your UHC commercial plan covers Amjevita or another adalimumab biosimilar as preferred, ask Amgen or the biosimilar manufacturer about copay assistance programs — these may significantly reduce your out-of-pocket cost. Copay assistance is only available to commercially insured patients; Medicare and Medicaid members are not eligible. Confirm enrollment timing before your first fill.
Options if UnitedHealthcare 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.
Amjevita (adalimumab-atto) / Nuvaila
OptumRx-preferred adalimumab biosimilar as of January 2025 on most UHC commercial plans; Nuvaila is the OptumRx/Optum private-label version of Amjevita. Same active ingredient as branded Humira; FDA-approved for all Humira indications. Available from OptumRx specialty pharmacy.
Enbrel (etanercept)
TNF inhibitor biologic DMARD for RA, PsA, and ankylosing spondylitis. No marketed biosimilar (Erelzi/Eticovo blocked until April 2029). Subject to PA and step therapy at UHC/OptumRx; may be preferred over adalimumab on some UHC plan formularies depending on indication.
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 option after TNF inhibitors. Specialty tier with PA and step therapy at UHC/OptumRx.
These options are listed for information only — your own clinician decides what is appropriate for you.
❓Frequently Asked Questions
OptumRx — UHC's pharmacy benefit manager — excluded brand Humira from most commercial formularies effective January 2025, in favor of Amgen's Amjevita adalimumab biosimilar (including the Nuvaila private-label). On some formularies (OptumRx Select Standard), brand Humira remains on Tier 3 with prior authorization. So the answer is: brand Humira is excluded from most standard UHC commercial plans, but access may still be possible through PA on select formularies. Verify your specific UHC plan via OptumRx.
Nuvaila is OptumRx's private-label branded version of Amjevita (adalimumab-atto, manufactured by Amgen), the FDA-approved biosimilar for Humira. It contains the same adalimumab active ingredient and is approved for the same FDA indications as branded Humira. OptumRx designated Amjevita/Nuvaila as the preferred adalimumab product on standard commercial formularies in January 2025, replacing branded Humira. Your prescriber can advise whether the biosimilar is appropriate for your specific indication.
On most standard OptumRx commercial formularies, brand Humira is excluded as of January 2025. Access may still be possible on OptumRx Select Standard formularies (Tier 3 with PA) or through a medical exception / appeals process if your prescriber documents a clinical reason the preferred biosimilar is not appropriate. Verify your specific plan formulary on optumrx.com or myuhc.com, and ask your prescriber about your options.
Yes. For UHC Medicare members, adalimumab covered on the Part D specialty tier is subject to the $2,100 (2026) annual out-of-pocket cap. Once you reach that cap for the year, you pay $0 for all covered Part D drugs for the rest of the calendar year. The specific preferred adalimumab product (brand or biosimilar) on your UHC Medicare plan depends on your specific plan formulary — verify via myuhc.com or by calling member services.
OptumRx requires PA for adalimumab, including documentation of the FDA-approved indication, relevant clinical assessments, and prior conventional DMARD or biologic trial history depending on the indication. For standard commercial formularies, the preferred product is Amjevita/Nuvaila — if brand Humira is requested, a documented medical necessity reason must be provided. PA approval is typically 12 months and requires annual renewal with evidence of continued clinical response.
Related Articles
Does Aetna Cover Vyvanse? 2026 CVS Caremark Formulary
Aetna covers Vyvanse via CVS Caremark — generic lisdexamfetamine preferred, brand non-preferred. 70 mg/day QL per Policy 5.60.024; age-22 PA required.
Read moreDoes Aetna Cover Prolia? CVS Caremark Medical Benefit | Curex
Aetna covers Prolia under the medical benefit with PA — a q6-month clinic injection, not Part D. Jubbonti biosimilar now preferred on CVS Caremark.
Read moreDoes Anthem Cover Adderall? 2026 Coverage Guide | Curex
Anthem covers Adderall through CarelonRx — generic preferred, brand non-preferred. Step therapy may apply on some plans. Verify your Anthem plan.
Read moreDoes Anthem Cover Contrave? 2026 Brand Coverage Guide | Curex
Anthem covers Contrave only if your plan has a weight-loss benefit. Many plans carve it out. CurAccess ~$99/mo is often the fastest path.
Read moreDoes Aetna Cover Contrave? 2026 CVS Caremark Guide | Curex
Aetna (CVS Caremark) often excludes Contrave under AOM carve-outs. Where covered, CVS BMI prior auth applies. Medicare bars it by law. CurAccess ~$99/mo.
Read moreDoes Aetna Cover Forteo? 2026 Coverage Guide
Aetna (CVS) often excludes brand Forteo in favor of generic teriparatide or Bonsity. Teriparatide is covered with PA and bisphosphonate step therapy. 2026.
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 UnitedHealthcare before making any decision. Consult a licensed healthcare provider and your plan administrator for guidance specific to your situation.