CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Ilumya

Policy governs coverage, prior authorization criteria, dosing, quantity limits, and continuation criteria for Ilumya (tildrakizumab) across Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members (pharmacy scope: Medicaid).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyIlumya

Policy CodePolicy N/A

Change TypeReviewed (no material clinical change)

Effective DateJan 1, 2020

Next Review Date

Key ActionRequests must meet all initial criteria including age, diagnosis, TB screening, specialist involvement, prior therapy trials/intolerance, and cannot be used concomitantly with other specified biologics; approvals are for 12 months.

SourceLink

POLICY UPDATE CHANGES

Policy review dates updated multiple times through 1/2025; effective date listed as 1/2020.

1Covered J-code

12 moInitial coverage duration

100 mg/12 wksStandard dosing limit

18+Minimum age

Coverage Summary

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Policy status: CURRENT. Coverage stance: covered_with_criteria for Ilumya (tildrakizumab) to treat moderate to severe plaque psoriasis. Scope: applies to Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members; pharmacy scope: Medicaid. Effective date: 2020-01-01. Last review date: 2025-01-01.

Key thresholds

Minimum age18 years

Initial coverage duration12 months

Standard dosing limit100 mg per 12 weeks

Loading dose allowance200 mg per month (post-limit)

Severity threshold>= 10% body surface area OR involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)