CurrentColorado Rocky Mountain Health PlansPolicy N/A

Ilumya (tildrakizumab-asmn) prior authorization

Prior authorization and reauthorization requirements for Ilumya (tildrakizumab-asmn) for treatment of adults with moderate to severe plaque psoriasis; applies to UnitedHealthcare pharmacy clinical programs and affects providers submitting PA requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyIlumya (tildrakizumab-asmn) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2025

Next Review DateOct 1, 2025

Key ActionSubmit prior authorization showing diagnosis of moderate to severe plaque psoriasis and that the patient is not receiving Ilumya with another systemic targeted immunomodulator.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsauthorization duration

Adultsindicated population

Excludedcoverage exclusion note

Prior Authprogram type

Coverage Criteria for Ilumya (tildrakizumab-asmn)

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.

Initial Authorization

Ilumya will be approved when ALL of the following are met:

Initial Authorization: Diagnosis of moderate to severe plaque psoriasis

Initial Authorization: Patient is not receiving Ilumya in combination with another systemic targeted immunomodulator (examples: etanercept, certolizumab, golimumab, abatacept, adalimumab, ustekinumab, risankizumab, guselkumab, secukinumab, ixekizumab, brodalumab, tofacitinib, baricitinib, upadacitinib, apremilast)

Authorization will be issued for 12 months.

Reauthorization

Ilumya will be reauthorized when ALL of the following are met:

Reauthorization: Documentation of positive clinical response to Ilumya therapy

Reauthorization: Patient is not receiving Ilumya in combination with another systemic targeted immunomodulator (examples: etanercept, certolizumab, golimumab, abatacept, adalimumab, ustekinumab, risankizumab, guselkumab, secukinumab, ixekizumab, brodalumab, tofacitinib, baricitinib, upadacitinib, apremilast)

Reauthorization will be issued for 12 months. State mandates and member-specific benefit plan coverage may affect approval.

Ilumya (tildrakizumab-asmn) is excluded from coverage for the majority of UnitedHealthcare benefits; whether a particular request will be covered depends on the member's specific benefit plan. Providers should verify the member’s pharmacy or medical benefit details before submitting a prior authorization request because exclusions at the program level may lead to automatic denial for many members.

Even when a member’s plan permits coverage, approvals follow the clinical criteria in this policy and may be subject to additional plan-level rules such as supply limits, Step Therapy, and Medical Necessity programs. UnitedHealthcare also reserves the right to approve initial or reauthorization requests based on previous claim/medication history, diagnosis codes, and/or automated claim logic where applicable.

Reauthorization / Continuation Therapy

Reauthorization/Continuation Therapy

Reauthorization/continuation is permitted when criteria are met:

Continuation: Documentation of positive clinical response to Ilumya therapy

Authorization for 12 months.

Continuation: Patient not receiving Ilumya in combination with another systemic targeted immunomodulator (examples listed)

Provider Requirements, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization required. Ilumya initial approvals require documentation of diagnosis and confirmation that therapy is not being used in combination with another systemic targeted immunomodulator. Authorization will be issued for 12 months.

Initial authorization requires: diagnosis of moderate to severe plaque psoriasis
Patient must NOT be receiving Ilumya in combination with another systemic targeted immunomodulator (examples: Enbrel, Cimzia, Simponi, Orencia, adalimumab, Stelara, Skyrizi, Tremfya, Cosentyx, Taltz, Siliq, Xeljanz, Olumiant, Rinvoq, Otezla)
Authorization duration: 12 months

Documentation Required

Reauthorization Documentation

Documentation required for reauthorization. Continued coverage requires evidence of positive clinical response and confirmation that Ilumya is not being used with another systemic targeted immunomodulator.

Reauthorization requires documentation of positive clinical response to Ilumya
Patient must NOT be receiving Ilumya in combination with another systemic targeted immunomodulator (see examples listed under initial authorization)

Denial Risk

Denial Risks & Additional Rules

Denial risks: submissions lacking the required diagnosis, lacking documentation of positive response at reauthorization, or indicating concurrent use with another systemic targeted immunomodulator may be denied. Additionally, Ilumya may be excluded from coverage depending on the member's benefit plan; supply limits, Step Therapy, and Medical Necessity programs may also apply and affect approval.

Denial triggers: wrong or missing diagnosis (not moderate to severe plaque psoriasis)
Denial triggers: absence of documentation of positive clinical response for reauthorization
Denial triggers: concurrent use with another systemic targeted immunomodulator
Ilumya may be excluded from coverage for many benefit designs — check member plan
Supply limits, Step Therapy, and Medical Necessity programs may apply

Definitions and Concomitant Therapy Restrictions

Systemic targeted immunomodulators not permitted with Ilumya

Not permitted in combinationIlumya may not be used in combination with another systemic targeted immunomodulator for approval.

Examples (biologic TNF/IL modulators)Enbrel (etanercept); Cimzia (certolizumab); Simponi (golimumab); Stelara (ustekinumab); Skyrizi (risankizumab); Tremfya (guselkumab); Cosentyx (secukinumab); Taltz (ixekizumab); Siliq (brodalumab)

Examples (non-biologic targeted agents)Xeljanz (tofacitinib); Olumiant (baricitinib); Rinvoq (upadacitinib); Otezla (apremilast)

Authorization impactRequests with concurrent use of any listed systemic targeted immunomodulator may be denied; authorization is contingent on absence of combination therapy.

Step	Requirement / Note
1	Supply limits, Step Therapy, and/or Medical Necessity may be in place; specific step requirements are not provided in this document.

Background on Ilumya (tildrakizumab-asmn)

Ilumya (tildrakizumab-asmn) is an interleukin-23 antagonist indicated for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy. The policy’s approval framework is limited to adult patients and requires documentation of the diagnosis of moderate to severe plaque psoriasis.

For initial authorization, approval requires that the patient has the qualifying diagnosis and is not receiving Ilumya in combination with another systemic targeted immunomodulator (examples are listed in the policy). Reauthorization requires documentation of a positive clinical response to Ilumya and that the patient is not receiving concurrent systemic targeted immunomodulator therapy. When approved, authorizations are issued for 12 months.