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Ilumya® (tildrakizumab) (Revised)
Act
by May 27, 2026
Effective date
May 27, 2026
Identified
Jun 25, 2026
Summary
Humana revised its Ilumya (tildrakizumab) prior authorization policy for Medicare and Medicaid (South Carolina) effective May 27, 2026. The policy now requires step therapy with TNF inhibitors (Remicade/Inflectra/Infliximab) AND a preferred ustekinumab product (Stelara/Otulfi/Yesintek) before Ilumya approval, with an exception for Medicare Part B continuation therapy within 365 days. Combination therapy with other biologics remains excluded.
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What to do
by May 27, 2026 · 6 steps
01Billing and clinical teams must update prior authorization workflows to require documented failure or intolerance with BOTH a TNF inhibitor (Remicade, Inflectra, or Infliximab) AND a preferred ustekinumab product (Stelara, Otulfi, or Yesintek) before submitting Ilumya prior auth requests.
02For Medicare Part B continuation therapy claims submitted within 365 days of prior approval, bypass step therapy requirements.
03Update authorization templates and clinical documentation requirements in billing system.
04Ensure providers document specific reasons for prior therapy failure (e.g., loss of efficacy, adverse reactions).
05Flag any Ilumya requests lacking dual prior therapy documentation for denial.
06Communicate step therapy requirements to prescribing dermatologists and rheumatologists.
Codes mentioned
J7211
Original notice
Ilumya® (tildrakizumab) (Revised)
mcp.humana.com · Always check the source before changing claims.