CommercialPrior AuthMedium impact
Tildrakizumab-asmn (IIumya®)
BCBS Tennessee·TN · Dermatology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
BlueCross BlueShield of Tennessee is implementing a new prior authorization policy for Tildrakizumab-asmn (Ilumya®), a biologic treatment for moderate to severe plaque psoriasis. Coverage requires specific clinical criteria including prior biologic/targeted synthetic therapy, affected crucial body areas, or significant BSA involvement. The policy becomes effective September 30, 2026, and requires dermatologist prescription with documented TB screening and BSA assessment.
Action Required
By September 30, 2026: Billing team must implement prior authorization workflow for Ilumya (Tildrakizumab-asmn) claims in the billing system. (1) Configure system to require prior auth for all Ilumya prescriptions for plaque psoriasis. (2) Update claim submission templates to require documentation of: prior biologic/targeted synthetic therapy (e.g., Sotyktu, Otezla), OR affected crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas), OR ≥10% BSA involvement, OR ≥3% BSA with phototherapy/systemic agent failure or clinical contraindication. (3) Ensure prior auth requests include chart notes showing BSA affected and clinical justification. (4) Verify all prescriptions are from dermatologists or in consultation with dermatology. (5) Implement continuation of therapy tracking requiring documentation of BSA reduction or symptom improvement at 12-month intervals. (6) Flag claims if TB screening documentation is missing prior to treatment initiation. Consequences: Claims without proper prior authorization and supporting documentation will be denied; requests missing dermatologist validation will be rejected.