CurrentAvMedPolicy N/A

Ilumya (tildrakizumab-asmn) pharmacy prior authorization and step-edit

This form governs prior authorization and step-therapy requirements for pharmacy benefit coverage of Ilumya (tildrakizumab-asmn) for AvMed members, including documentation and prescriber signature requirements. It applies to providers submitting pharmacy PA requests for this drug.

Policy Summary

PayerAvMed

PolicyIlumya (tildrakizumab-asmn) pharmacy prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed pharmacy PA/step-edit form with prescriber signature and supporting documentation to request prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100 mgrecommended SubQ dose

wks 0,4; q12wdosing schedule

>=3 mophototherapy/systemic trial

90 dayscontinuation criterion

Coverage Criteria for Ilumya (tildrakizumab-asmn)

Initial and continuation coverage criteria

Covered when ALL of the following are met:

Primary criteria: Member has a diagnosis of moderate-to-severe plaque psoriasis

All documentation (labs, diagnostics, and/or chart notes) must be provided to support each checked item

Prescriber requirement: Prescribed by or in consultation with a Dermatologist

Prior therapy requirement: Member tried and failed at least one of either phototherapy or an alternative systemic therapy for at least three (3) months3 months

Phototherapy options include UV Light Therapy, NB UV-B, PUVA; alternative systemic oral agents include acitretin, methotrexate, cyclosporine

Policy Summary

PayerAvMed

PolicyIlumya (tildrakizumab-asmn) pharmacy prior authorization and step-edit

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed pharmacy PA/step-edit form with prescriber signature and supporting documentation to request prior authorization.

SourceLink

On This Page

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Initial Therapy Requirements

Initial therapy

Initial approval requires meeting prescriber and prior therapy criteria:

Diagnosis and prescriber: Diagnosis of moderate-to-severe plaque psoriasis AND prescribed by or in consultation with a Dermatologist

All documentation must be provided to support the request

Prior therapy: Failure of at least one phototherapy OR failure of at least one alternative systemic oral agent for >=3 months3 months

Phototherapy options: UV Light Therapy, NB UV-B, PUVA. Alternative systemic oral agents: acitretin, methotrexate, cyclosporine

Alternate biologic pathway: Failure, contraindication, or intolerance to TWO preferred biologics as documented (verified by chart notes or pharmacy paid claims)2 biologics

Preferred biologics listed on form must be used to demonstrate this pathway

Step Therapy Requirements

Step	Requirement
1	Trial of at least one phototherapy or one alternative systemic therapy for at least 3 months (phototherapy options: UV Light Therapy, NB UV-B, PUVA; alternative systemic oral agents include acitretin, methotrexate, cyclosporine). Failures must be documented by chart notes or pharmacy paid claims.
2	Alternatively, documented trial and failure, intolerance, or contraindication to TWO preferred biologics (e.g., preferred adalimumab product, Enbrel, Otezla/Otezla XR, Skyrizi, Sotyktu, Taltz, Tremfya, preferred ustekinumab product). Failures/intolerances must be verified by chart notes or pharmacy paid claims.
3	Established therapy exception: Member has been on Ilumya for at least 90 days AND pharmacy claims show at least a 90‑day supply dispensed within the past 130 days (verification by chart notes or pharmacy paid claims).

Coding and Therapy Duration Requirements

inv-04: Required duration of prior phototherapy or systemic therapy (months)

Required prior therapy durationMember must have tried and failed at least one phototherapy or an alternative systemic therapy for at least 3 months (>=3 months)

Acceptable phototherapy optionsUV Light Therapy, NB UV-B, PUVA (each must be trialed as applicable for >=3 months)

Acceptable alternative systemic optionsOral agents include acitretin, methotrexate, cyclosporine (trial >=3 months)

inv-05: Established Ilumya therapy evidence — at least a 90-day supply dispensed within the past 130 days.

Established Ilumya therapy requirementMember has been established on Ilumya for at least 90 days and prescription claims show at least a 90-day supply dispensed within the past 130 days

VerificationEstablished therapy must be verified by chart notes or pharmacy paid claims

Timing windowDispensed 90-day supply must be within the prior 130 days

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Ilumya (tildrakizumab-asmn) requires prior authorization via the pharmacy PA/step-edit request form. The prescribing physician must sign and clearly print their name (preprinted stamps not valid). Fax completed forms to 1-305-671-0200. Incomplete, incorrect, illegible, or missing information (including phone/fax, member identifiers, or supporting documentation) may delay or result in denial of the authorization.

Drug: Ilumya (tildrakizumab-asmn) (Pharmacy)
Fax: 1-305-671-0200
Prescriber signature and printed name required (stamps not valid)

Step Therapy

Step Therapy Requirements

Step therapy/step-edit requirements apply. Member must have a diagnosis of moderate-to-severe plaque psoriasis and treatment must be prescribed by or in consultation with a dermatologist. Member must have tried and failed at least one phototherapy OR an alternative systemic therapy for at least 3 months (phototherapy options: UV Light Therapy, NB UV-B, PUVA; alternative systemic options: acitretin, methotrexate, cyclosporine, or other oral medications). Alternatively, member must have tried and failed or have contraindication/intolerance to two preferred biologics (verified by chart notes or pharmacy paid claims). Continuation criteria: member established on Ilumya for ≥90 days with prescription claims showing at least a 90-day supply dispensed within the past 130 days.

Diagnosis: moderate-to-severe plaque psoriasis
Prescriber: Dermatologist or in consultation with Dermatologist
Phototherapy trial ≥3 months OR Alternative systemic therapy trial ≥3 months
Or failure/contraindication/intolerance to two preferred biologics (documented)
Continuation: ≥90 days established on Ilumya with ≥90-day supply dispensed within past 130 days

Documentation Required

Required Form Fields and Supporting Documentation

Required form fields and supporting documentation must be provided. Include member identifiers (member name, AvMed #, DOB), prescriber information (name, NPI, office contact, phone and fax), prescriber signature and date, drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code, weight (if applicable) and date obtained, and the recommended dosing (SubQ: 100 mg at weeks 0, 4, then every 12 weeks). Provide supporting clinical documentation (chart notes, lab results, diagnostics) verifying prior therapies, contraindications/intolerances, and pharmacy paid claims where indicated.

Member name, AvMed #, DOB
Prescriber name, NPI, office contact, phone, fax, signature and date
Drug name/form/strength, dosing schedule, length of therapy
Diagnosis and ICD code, weight and date weight obtained
Recommended dosing: SubQ 100 mg at weeks 0, 4, then every 12 weeks thereafter
Supporting documentation: chart notes, lab results, diagnostics, pharmacy paid claims to verify prior therapies

Denial Risk

Incomplete or Missing Documentation

Incomplete or missing documentation may delay the authorization process or result in denial. Use of samples to initiate therapy does not meet step-edit/preauthorization criteria. The Health Plan will not permit concomitant use of more than one biologic immunomodulator for the same or different indications (considered experimental/investigational).

Incomplete/incorrect/illegible forms can delay or deny authorization
Samples do not meet step-edit or preauthorization criteria
Concomitant biologics are considered experimental and will not be permitted (e.g., Dupixent, Entyvio, Humira, Rinvoq, Stelara)

Definitions and Diagnostic Requirements

inv-11: Moderate-to-severe plaque psoriasis definition — diagnosis required for approval; provider must be a dermatologist or in consultation per form.

Required diagnosis for approvalDiagnosis of moderate-to-severe plaque psoriasis (must be checked on the form)

Prescriber requirementPrescribed by or in consultation with a Dermatologist (must be indicated on the form)

Supporting documentationAll documentation (lab results, diagnostics, chart notes) must be provided to support criteria or request may be denied

Concomitant biologics policyUse of more than one biologic immunomodulator concurrently is considered experimental/investigational and will not be permitted

OpenPayer

Ilumya (tildrakizumab-asmn) pharmacy prior authorization and step-edit

Coverage Criteria for Ilumya (tildrakizumab-asmn)

Initial Therapy Requirements

Continuation Therapy Requirements

Step Therapy Requirements

Coding and Therapy Duration Requirements

Quantity Limits and Dosing

Provider Actions and Documentation Requirements

Definitions and Diagnostic Requirements

Background