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Ilumya® (tildrakizumab) (Revised)
Act
by Sep 25, 2024 (or immediately if already past this date)
Effective date
Sep 25, 2024
Identified
Jun 25, 2026
Summary
Humana updated its Ilumya (tildrakizumab) prior authorization policy effective September 25, 2024. The policy maintains existing coverage criteria for moderate to severe plaque psoriasis but emphasizes mandatory prior authorization, strict failure/intolerance requirements for two specific biologic classes (TNF inhibitors and Stelara), and explicit exclusion of combination biologic therapy. Billing teams must ensure all Ilumya requests meet these tightened criteria before submission.
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What to do
by Sep 25, 2024 (or immediately if already past this date) · 8 steps
01Billing team must update prior authorization workflows to enforce the revised Ilumya criteria.
02Update billing system to flag all Ilumya requests requiring prior auth verification.
03Ensure providers document failure or intolerance to BOTH (a) Remicade/unbranded Infliximab/Inflectra AND (b) Stelara before submission—claims will be denied without evidence of prior failure to these two specific drug classes.
04Add system check to block claims showing concurrent biologic use (Cosentyx, Enbrel, adalimumab products, Kevzara, Remicade)—these are exclusionary and will trigger denial.
05Verify member age ≥18 years on all submissions.
06Confirm diagnosis is moderate to severe plaque psoriasis (ICD-10: L40.0, L40.9, or related psoriasis codes).
07Provider relations team should communicate to dermatology practices that prior auth is non-negotiable and documentation of dual prior therapy failure is mandatory.
08Claims submitted without evidence of the required prior treatment failures will be denied.
Codes mentioned
J3245
Original notice
Ilumya® (tildrakizumab) (Revised)
mcp.humana.com · Always check the source before changing claims.