Updates to the Preferred Drug List (PDL) - Cytokine and CAM Antagonist Drug Class Effective January 1, 2026

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Bulletin

November 20, 2025, 12:54PM

To:

All Providers and Managed Care Organizations Participating in the Virginia Medical Assistance Program

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to notify providers of updates to the Cytokine and Cell Adhesion Molecule (CAM) Antagonist drug class on the Medicaid Preferred Drug List (PDL). Effective January 1, 2026, the adalimumab biosimilars noted below are preferred over the reference product (Humira). By the effective date, ALL members, including those currently stabilized on Humira, must be transitioned to one of the preferred biosimilars below. Any current authorizations that may be in place for Humira will end December 31, 2025 and transitioned to authorization for a biosimilar.

These changes are being made in accordance with the decisions made by the Department’s Pharmacy and Therapeutics Committee in October 2025. For more information about this and other decisions made by the Pharmacy and Therapeutics Committee at the October meeting, please review the bulletin here.

Summary of Changes:

Drug Name

Status

New PDL Status

Notes

Adalimumab-adbm (unbranded Cyltezo)

Added

Preferred

Max dose available 40mg. Multiple units needed for higher doses.

Adalimumab-bwwd (Hadlima)

Added

Preferred

Max dose available 40mg. Multiple units needed for higher doses.

Adalimumab (Humira)

Status Change

Non-Preferred

Branded Reference Product

The preferred biosimilar products are interchangeable with the branded reference product in alignment with the commitment to both optimal clinical outcomes and fiscally responsible healthcare.

We value our continued partnership in caring for our mutual member populations. Our goal is to ensure a seamless transition process to biosimilar products for members, providers, and pharmacies. For further information or support, please contact the respective Health Plan or Fee-for-Service pharmacy-specific number below.

Medicaid Fee-for-Service

800-932-6648

Aetna Better Health of Virginia

800-279-1878

Anthem HealthKeepers Plus

800-901-0020

Humana Healthy Horizons

800-555-2546

Sentara Community Plan

877-475-4355

United Healthcare

800-310-6826

Questions can be directed to PharmacyTeam@DMAS.Virginia.gov

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627