CurrentCignaPolicy CNF168

Inflammatory Conditions – Ilumya Drug Quantity Management Policy – Per Days - (CNF168)

Defines quantity limit and exception criteria for Ilumya (tildrakizumab-asmn) 100 mg/1 mL prefilled syringe for Cigna-administered health benefit plans, including point-of-service drug quantity management rules and one-time overrides.

Policy Summary

PayerCigna

PolicyInflammatory Conditions – Ilumya Drug Quantity Management Policy – Per Days - (CNF168)

Policy CodePolicy CNF168

Change TypeClarifiedRevised

Effective Date

Next Review Date

Key ActionIf the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria; providers must ensure prior claims history shows no Ilumya in past 130 days to qualify for a one-time override.

SourceLink

POLICY UPDATE CHANGES

Policy Statement updated to clarify that 'One-time' overrides are provided for 30 days in duration.

Annual revisions noted with no criteria changes on multiple review dates.

1Standard syringes allowed per 84 days

2Syringes allowed for one-time induction override

130Lookback period (days)

Coverage Summary

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Drug Quantity Limits & Provider Requirements

Drug Quantity Limits and Exceptions

Ilumya maximum quantity per 84 days is 100 mg (1 syringe). Exceptions covered as medically necessary when ALL of the following are met:

ALL of the following

Patient is initiating treatment or requires additional induction dosing
Verified by absence of claims for Ilumya in the past 130 days
Approve a one-time override for 200 mg (2 syringes) at retail or home delivery200 mg (2 syringes)
One-time overrides are provided for 30 days in duration

Prior Authorization

Drug quantity management at point of service

If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria; providers must ensure prior claims history shows no Ilumya in past 130 days to qualify for a one-time override.

Ensure there are no Ilumya claims in the past 130 days to qualify for a one-time override.

Billing Rule

Standard quantity limit per 84 days

Ilumya should be billed consistent with a maximum of 100 mg (1 syringe) per 84 days unless an approved exception is documented.

Bill Ilumya consistent with a max of 100 mg (1 syringe) per 84 days.

Documentation Required

Documentation to support induction override

Providers must document absence of Ilumya claims in the past 130 days to support approval for the one-time 200 mg (2 syringe) override.

Document that there are no Ilumya claims in the past 130 days.

Definitions & Background

One-time override: a single approval to exceed the standard quantity limit; per policy this override is for 30 days and permits 200 mg (2 syringes) when the criteria are met.

Ilumya is indicated for the treatment of moderate to severe plaque psoriasis in adults. The recommended dosing is 100 mg administered by subcutaneous injection at Weeks 0 and 4 and then once every 12 weeks thereafter. The policy allows a one-time 200 mg (2-syringe) override for patients initiating treatment or requiring induction dosing when there are no Ilumya claims in the prior 130 days, and the override duration is 30 days.

Revision History

01/03/2024review

Annual revision — No criteria changes.

02/10/2025revision

Policy Statement updated to clarify that 'One-time' overrides are provided for 30 days in duration.

02/05/2026reviewLatest

Annual revision — No criteria changes. Latest review date.

policy_detail

Standard quantity limit: Ilumya maximum quantity per 84 days is 100 mg (1 syringe); one-time override allows 200 mg (2 syringes) when initiating treatment or requiring induction, verified by absence of Ilumya claims in the past 130 days; one-time overrides are provided for 30 days in duration; dosing is 100 mg SC at Weeks 0 and 4 then every 12 weeks; Ilumya available as 100 mg/1 mL prefilled syringe.