When your insurance company tells you that Humira is no longer covered and you need to switch to a different adalimumab product, it sounds like a medical decision. It isn't. It's a financial one — and understanding who's making it and why is important for any patient trying to navigate this system.
The Three Private-Label Biosimilars
Over the past two years, the three largest pharmacy benefit managers in the United States created their own branded adalimumab biosimilar products:
- CVS Caremark formed a subsidiary called Cordavis, which distributes Hyrimoz (made by Sandoz) under its own branding
- Optum Rx (UnitedHealth Group's PBM) created Nuvaila
- Express Scripts (Cigna's PBM) launched Quallent
These aren't new drugs. They're existing FDA-approved biosimilars distributed through a PBM-controlled entity, which allows the PBM to capture more of the margin that would otherwise go to the biosimilar manufacturer.
Each of these PBMs then restructured its formulary to make the private-label biosimilar the preferred product — and removed brand Humira and most independent biosimilars from preferred tiers or excluded them entirely.
What This Means for Patients
If your prescription coverage is through CVS Caremark, Optum Rx, or Express Scripts, you've likely been (or will soon be) routed to whichever private-label adalimumab product your PBM prefers — not because it's clinically superior, not because your doctor chose it, but because it's more profitable for your insurer's subsidiary.
Clinically, this isn't a problem. These are FDA-approved biosimilars with equivalent efficacy. But a few downstream effects are worth knowing about:
Copay assistance cards may not apply. When you're dispensed a private-label or specialty-distributed biosimilar rather than the manufacturer's branded version, the manufacturer's copay assistance card may not apply. Cordavis, Nuvaila, and Quallent have their own savings programs — but the terms differ from the manufacturer-direct offerings.
Patient assistance programs may be harder to access. PAPs are typically manufacturer-run. If you're being dispensed a PBM-distributed version of a biosimilar, the relationship between you, the drug, and the manufacturer's assistance programs becomes more complicated. Call both the PBM's specialty pharmacy and the underlying manufacturer.
You may have fewer choices than you think. On paper, there are ten FDA-approved adalimumab biosimilars. In practice, your plan may effectively cover only one — the one your PBM profits from. Other biosimilars may require prior authorization, be placed on excluded tiers, or come with significantly higher cost-sharing.
Is This Legal?
Yes. PBMs are not required to include every FDA-approved drug on their formularies, and they're permitted to create subsidiaries that distribute drugs. The practice is controversial — and increasingly under Congressional scrutiny — but it's currently legal.
Several state attorneys general and federal legislators have raised concerns about PBM vertical integration and the conflict of interest it creates when the entity managing your drug benefits also profits from which drugs you use. As of 2026, meaningful federal regulation of PBM practices remains pending.
What You Can Do
Understand your formulary. Log in to your insurer's portal and look up "adalimumab" — not just "Humira." See which products are covered, which tier they're on, and what the cost-sharing looks like for each. If your plan only lists one or two options with no cost-sharing difference, that's the PBM's fingerprints.
Ask about medical exceptions. If your prescriber believes a specific adalimumab product is medically necessary for you (for example, if a different formulation caused injection-site reactions, or if you've been stable on Humira for years), a formal medical exception request can be filed. These succeed more often than patients expect when supported by prescriber documentation.
Don't let cost-sharing decisions override clinical judgment. Your prescriber should be making adalimumab decisions based on your clinical situation, not which product your PBM happens to be distributing this year. If you feel the decision is being made for you without clinical justification, ask your doctor explicitly: "Is there a medical reason for this specific product, or is this a cost decision?"
Look at the underlying assistance programs. Regardless of which adalimumab product you end up on, the underlying manufacturer (Sandoz for Hyrimoz/Cordavis, for example) has patient assistance programs that may apply. The PBM's branding doesn't change what the manufacturer offers.
ClariMeds identifies which assistance programs apply to your specific plan and product — including in these PBM private-label situations.
Check your options — about 5 minutes
This article contains general information about pharmaceutical pricing and PBM practices. It is not medical or legal advice.