Medicare AdvantagePrior AuthMedium impact
Ilumya® (tildrakizumab) (Revised)
Humana·SC · Dermatology, Rheumatology·Medicaid
Effective date
May 27, 2026
We identified it
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.
Action Required
By May 27, 2026: Billing 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. For Medicare Part B continuation therapy claims submitted within 365 days of prior approval, bypass step therapy requirements. Update authorization templates and clinical documentation requirements in billing system. Ensure providers document specific reasons for prior therapy failure (e.g., loss of efficacy, adverse reactions). Flag any Ilumya requests lacking dual prior therapy documentation for denial. Communicate step therapy requirements to prescribing dermatologists and rheumatologists.