Ilumya (tildrakizumab-asmn) Precertification Request — Coverage Criteria
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Precertification and clinical information requirements for Aetna members when requesting Ilumya for plaque psoriasis, including documentation needed for initiation and continuation of therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Ilumya (tildrakizumab-asmn)
Initial Therapy (implied)
Covered when ALL of the following are met (form requests documentation):
Form fields collect each element
Continuation Therapy (implied)
Continued coverage when ALL of the following are met:
Form continuation section requests these data
Use of Ilumya in combination with another biologic or targeted synthetic agent must be clearly indicated on the precertification form. The form asks specifically whether the requested drug will be used in combination with any other biologic (for example, Humira) or targeted synthetic drug (for example, Olumiant, Otezla, Xeljanz), and requires a yes/no response. Concurrent combination use is queried and would require documentation to support the combined regimen.
Coding and Clinical Data Fields
| Administration code(s) (CPT): | Place to list CPT administration codes if applicable as indicated on form |
| Primary ICD Code: | Primary diagnosis ICD-10 code field |
| Secondary ICD Code: | Secondary diagnosis ICD-10 code field |
| Other ICD Code: | Other diagnosis ICD-10 code field |
Provider Actions and Documentation Requirements
Precertification required
Precertification is required for Ilumya; submit the Ilumya Medication Precertification Request form with all required clinical information for start or continuation of therapy.
Prior therapy / inadequate response query
The form asks whether the patient has had an inadequate response or intolerance to phototherapy or systemic agents (methotrexate, cyclosporine, acitretin), and requires this information when BSA is <10%.
Completion requirements
Complete and legible completion of all required fields on the precertification form is required, including patient demographics, insurance/contact, prescriber and dispensing provider details, product (Ilumya) dose and frequency, and primary/secondary ICD codes; continuation requests must include maintenance dose and frequency.
- Patient demographics and contact information (chunk 1).
- Prescriber information including specialty and identifiers (chunk 3).
- Product information: Ilumya dose and frequency (chunk 5).
- Diagnosis ICD codes (chunk 6).
- Continuation-specific fields: maintenance dose/frequency and clinical response (chunk 10).
- Signature and date required on acknowledgement (chunk 11).
Incomplete documentation risk
Failure to provide required clinical documentation—such as TB testing history and results within 6 months, prior biologic use, BSA, or leaving required form fields incomplete—may prevent completion of the precertification review and could delay or deny processing.
- TB test recency and results must be reported (e.g., PPD, IGRA, chest x-ray) (chunk 7).
- Required clinical fields (prior biologic/targeted synthetic use, BSA, prior treatments/response) must be completed (chunks 7 and 9).
- Unsigned or undated forms may prompt requests for additional information or result in incomplete review (chunk 11).
Background
Ilumya (tildrakizumab-asmn) is a biologic therapy indicated for moderate to severe plaque psoriasis. The Ilumya precertification request form requires documentation of the indication and clinical severity for both new starts and continuation requests.
For initiation, the form requests documentation that the patient has plaque psoriasis, the proposed loading dose (weeks 0 and 4), the maintenance dose and dosing frequency, prior therapies (including phototherapy and systemic agents), history of prior biologic or targeted synthetic therapy, and tuberculosis (TB) screening performed within 6 months of initiating therapy with test type and result recorded.
For continuation requests, the form requests the current maintenance dose and frequency, documentation of clinical response or maintained benefit (for example, reduced body surface area and improvement in signs/symptoms), and confirmation of how the patient is currently receiving therapy (including samples or assistance programs). Provider signature and date are required on the acknowledgement section.
Definitions and Clinical Test Details
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