Q5143 Inj adalimumab-adbm, 1 mgInjection, adalimumab-adbm, biosimilar, 1 mg
Status N: non-covered service.
18 of 18 payer prior-auth lists that name Q5143 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Blue Shield of California Promise Health Plan, Cigna, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of New Mexico, Molina Healthcare of Utah, Passport by Molina Healthcare (Kentucky).
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth required | Request from member's PBM | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Cigna | ACA/IFP | All | prior auth required | Jan 1, 2025 | Master Precertification List (For Health Care Providers) | |
| Cigna | Basic Standard | All | prior auth required | Jan 1, 2025 | Master Precertification List (For Health Care Providers) | |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | Jan 1, 2025 | Master Precertification List (For Health Care Providers) | |
| Humana | Humana Healthy Horizons | OK | prior auth required | Oct 14, 2026 | Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List | |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 | |
| Molina Healthcare of California | Medicaid | CA | prior auth required | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 | |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 | |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | Jan 1, 2025 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | Molina follows New Mexico Senate Bill 135 Section 59A-22B-8 and waives PA where applicable | Jan 1, 2025 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
Q5143 appears in 38 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Cigna, Premera Blue Cross.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Abatacept (Orencia) (0720) Rinvoq, Xeljanz, Otezla, Ruxolitinib, Hydroxychloroquine, Sulfasalazine | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Adalimumab (0655) | covered if criteria are met | Jul 13, 2026 | payer document |
| Aetna | Alopecia Areata (0423) | not covered | Jul 10, 2026 | payer document |
| Aetna | Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments (0788) | not covered | Nov 19, 2025 | payer document |
| Aetna | Canakinumab (Ilaris) (0881) | not covered | Aug 3, 2026 | payer document |
| Aetna | Certolizumab Pegol (Cimzia) (0761) | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Complex Regional Pain Syndrome (CRPS): Treatments (0447) Ketamine metabolite (2R,6R)-hydroxynorketamine, metformin, topical ketamine, Topical dimethyl sulfoxide, Anakinra, Sarilumab - | not covered | Jul 16, 2026 | payer document |
| Aetna | Diabetic Neuropathy: Selected Treatments (0729) Fulranumab, Ozone Therapy, Ghrelin, Interleukin - 6, mecobalamin (a vitamin B12 analog), pulsed magnetic field treatment | not covered | Feb 24, 2026 | payer document |
| Aetna | Dupuytren's Contracture Treatments (0800) Cryopreserved placental membrane, manugraphy | not covered | Nov 20, 2025 | payer document |
| Aetna | Golimumab (Simponi and Simponi Aria) (0790) | listed, no stance | Jul 31, 2026 | payer document |
| Aetna | Graves' Ophthalmopathy Treatments (0419) Celecoxib, Gypenosides, Pioglitazone | not covered | Apr 23, 2026 | payer document |
| Aetna | Guselkumab (Tremfya) (1011) | listed, no stance | Jun 29, 2026 | payer document |
| Aetna | Infliximab (0341) | listed, no stance | Oct 5, 2026 | payer document |
| Aetna | Natalizumab (0751) Plegridy, Aubagio, Gilenya, Tecfidera, Mavenclad and Mayzent | listed, no stance | Dec 2, 2025 | payer document |
| Aetna | Parkinson's Disease (0307) | listed, no stance | Feb 24, 2026 | payer document |
| Aetna | Recurrent Pregnancy Loss (0348) Other HCPCS related to the CPB | covered if criteria are met | Jun 23, 2026 | payer document |
| Aetna | Rilonacept (Arcalyst) (0770) | listed, no stance | Sep 11, 2026 | payer document |
| Aetna | Secukinumab (Cosentyx) (0905) | listed, no stance | Aug 11, 2026 | payer document |
| Aetna | Tildrakizumab-asmn (Ilumya) (1012) | listed, no stance | Jul 1, 2026 | payer document |
| Aetna | Tocilizumab (0799) | listed, no stance | Jun 30, 2026 | payer document |
| Aetna | Tuberculosis Testing (0471) | listed, no stance | Jul 23, 2026 | payer document |
| Aetna | Vedolizumab (Entyvio) (0885) | listed, no stance | Jun 30, 2026 | payer document |
| Aetna | Vitiligo (0422) | not covered | Jul 16, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Antirheumatic Biologicals (L.5.01.404) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Biosimilar Medications (L.5.01.593) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Chronic Plaque Psoriasis (L.5.01.412) | covered if criteria are met | payer document | |
| Blue Cross & Blue Shield of Mississippi | Crohns Disease And Ulcerative Colitis (L.5.01.415) | listed, no stance | payer document | |
| Blue Cross & Blue Shield of Mississippi | Hidradenitis Suppurativa Hs (L.5.01.435) | covered if criteria are met | payer document | |
| Centene | Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab- bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz), Adalimumab-aacf (Idacio), Adalimumab-ryvk (Simlandi), Adalimumab-aaty (Yuflyma), Adalimumab-aqvh (Yusimry) (CP.PHAR.242) | covered if criteria are met | May 1, 2026 | payer document |
| Centene | Biologic and Non-biologic DMARDs (CP.CPA.194) | covered if criteria are met | May 1, 2026 | payer document |
| Centene | Biologic and Non-biologic DMARDs | covered if criteria are met | Aug 1, 2026 | payer document |
| Cigna | Inflammatory Conditions – Adalimumab Products Prior Authorization Policy (IP0652) | covered if criteria are met | May 1, 2026 | payer document |
| Premera Blue Cross | (effective January 1, 2027) Pharmacologic Treatment of Psoriasis (5.01.629) Page | 23 of 42 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Medical Necessity Criteria for Custom Open Formulary (5.01.647) Page | 48 of 69 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacologic Treatment of Psoriatic Arthritis (5.01.645) Page | 16 of 24 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacotherapy of Arthropathies (5.01.550) | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacotherapy of Inflammatory Bowel Disorder (5.01.563) Page | 38 of 74 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
| Premera Blue Cross | Pharmacotherapy of Miscellaneous Autoimmune Diseases (5.01.564) Page | 39 of 85 | ∞ | listed, no stance | Sep 8, 2026 | payer document |
Prior authorization required or conditional in IN, MS, NE, VT.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.