Draftblue cross blue shield - tennesseePolicy ID_CHS_2026

Ilumya (tildrakizumab-asmn) for plaque psoriasis — Coverage Criteria

Covers use of Ilumya for treatment of adult patients with moderate to severe plaque psoriasis when approval criteria are met; applies to BlueCross BlueShield of Tennessee members and providers subject to plan benefits.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyIlumya (tildrakizumab-asmn) for plaque psoriasis — Coverage Criteria

Policy CodePolicy ID_CHS_2026

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization with chart notes documenting BSA, prior therapies tried or reasons to avoid them, and TB screening results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization period granted

100 mgmaintenance dosing (subcutaneous)

every 12 weeksmaintenance dosing interval

≥18approved patient age group

10% BSABSA threshold for coverage

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Initial Therapy

Covered when ALL of the following are met

Population: Adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.age >=18

FDA‑approved indication

Disease extent criteria: At least one of: (1) ≥10% body surface area (BSA) affected; (2) involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); (3) ≥3% BSA affected AND either inadequate response or intolerance to phototherapy or methotrexate/cyclosporine/acitretin, OR a clinical reason to avoid those systemic agents.BSA and prior therapy requirements as specified

See Appendix for acceptable clinical reasons to avoid agents

Continuation Therapy

Covered when ALL of the following are met

Ongoing use: Member is currently using the requested medication for moderate to severe plaque psoriasis.

Includes new members who are stable on therapy; authorization of 12 months may be granted

Clinical response: Either improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain) OR reduction in body surface area (BSA) affected from baseline.clinical improvement or reduced BSA

Authorization of 12 months may be granted if criteria met

Requests for use of Ilumya (tildrakizumab-asmn) for indications other than the FDA-approved indication — treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy — are considered experimental/investigational and not medically necessary.

Do not administer the requested medication to members with active tuberculosis (TB) infection. Prior to initiating therapy, members must have documentation of TB evaluation, including a negative TB test (TST or IGRA) within 12 months for biologic‑naïve persons or further workup (for example, chest x‑ray) if screening is positive; latent TB must be treated before starting the medication.

Use of Ilumya for indications other than treatment of adult moderate to severe plaque psoriasis is not medically necessary.

Medication Dosing and Coding

Medication dosingmixed

Ilumya (tildrakizumab-asmn)

Product name and dosing regimen: 100 mg SC initial at weeks 0 and 4; maintenance 100 mg every 12 weeks

Body Surface Area (BSA) thresholds and related coverage conditions

Primary BSA threshold>= 10% body surface area (BSA) affected

Crucial area involvementAny involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Lower BSA with prior therapy failure>= 3% BSA affected AND inadequate response or intolerance to phototherapy (eg, UVB, PUVA) or systemic agents (methotrexate, cyclosporine, acitretin)

Lower BSA with clinical contraindication>= 3% BSA affected AND a documented clinical reason to avoid methotrexate, cyclosporine, or acitretin (see Appendix)

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests for this medication. Initial and continuation requests must include specified clinical documentation to support medical necessity and facilitate review.

Authorization may be granted for up to 12 months when criteria are met
Do not administer if active tuberculosis is present

Step Therapy

Step Therapy / Alternative Therapy Requirements

Step therapy / alternative therapy requirements: Document prior inadequate response or intolerance to phototherapy or specified systemic agents when applicable, or provide a clinical reason to avoid these therapies.

If relying on the "3% BSA + prior therapy" pathway, there must be documented inadequate response or intolerance to either phototherapy (e.g., UVB, PUVA) or pharmacologic treatment with methotrexate, cyclosporine, or acitretin.
Clinical reasons to avoid methotrexate, cyclosporine, or acitretin may include (but are not limited to) drug interactions, alcohol use disorder or chronic liver disease, pregnancy or planning pregnancy, breastfeeding, significant comorbidity (e.g., liver or kidney disease, blood dyscrasias, uncontrolled hypertension), history of intolerance/adverse event, or hypersensitivity.

Documentation Required

Initial Request Documentation Needed

Provider submission requirements for initial requests: Submit complete clinical documentation to support the request and demonstrate that coverage criteria are met.

Chart notes and medical records documenting affected area(s) and estimated body surface area (BSA) involved
Documentation or claims history of prior medications tried and response to those therapies (or documentation of a clinical reason to avoid specific therapies)
Evidence of prior phototherapy or systemic agent use when applicable (dates, dosing, response, or intolerance)
TB screening documentation: negative TST or IGRA within 12 months for biologic/targeted synthetic–naïve patients, and evaluation/management plan if testing is positive
Any other relevant clinical notes, labs, imaging, or specialist consults that support medical necessity

Denial Risk

Requests for Non–FDA‑Approved Indications / Denial Risk

Requests for non–FDA‑approved indications are not medically necessary. Provide indication-specific rationale and supporting evidence only for FDA‑approved use (treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy).

All other indications are considered experimental/investigational and will be denied
Do not authorize use in members with active tuberculosis; if latent TB is present, TB treatment must be initiated prior to therapy
Requested medication must not be used concomitantly with another biologic or targeted synthetic drug for the same indication

Background

Ilumya (tildrakizumab-asmn) is a biologic therapy FDA‑approved for the treatment of adult patients with moderate to severe plaque psoriasis (PsO) who are candidates for systemic therapy or phototherapy. As with other biologic and targeted synthetic agents that can increase the risk of tuberculosis, members must be evaluated for TB infection before initiation; documentation of a negative TB test (TST or IGRA) within 12 months or appropriate further evaluation when screening is positive is required. Clinical documentation of disease severity (for example, body surface area and involvement of crucial areas) and prior therapy history are used to determine medical necessity and authorization.

OpenPayer

Ilumya (tildrakizumab-asmn) for plaque psoriasis — Coverage Criteria

Coverage Criteria for Ilumya (tildrakizumab-asmn)

Medication Dosing and Coding

Provider Actions and Authorization Requirements

Definitions

Background