Aetna's Clinical Policy Bulletin 1012 covers tildrakizumab-asmn (Ilumya) for commercial medical plans, and precertification is required of all Aetna participating providers and members in applicable plan designs. Aetna considers Ilumya medically necessary for adult members with moderate to severe plaque psoriasis who have previously received a biologic or targeted synthetic drug, or who have crucial body areas affected, at least 10% of body surface area affected, or at least 3% affected along with an inadequate response to or intolerance of phototherapy or methotrexate, cyclosporine, or acitretin, or a clinical reason to avoid those drugs. Continuation is considered medically necessary when the member achieves or maintains a positive clinical response, shown by a reduction in body surface area from baseline or improvement in signs and symptoms from baseline.
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01Get precertification for Ilumya for these members: call (866) 752-7021 or fax (888) 267-3277.
02Providers: the medication must be prescribed by or in consultation with a dermatologist.
03Billing team: keep the chart documentation that shows the initial criteria are met, such as the prior biologic or targeted synthetic drug or the affected body areas or body surface area with the phototherapy or drug history, or the continuation response criteria.
04Confirm the member has been evaluated for tuberculosis infection before starting treatment, and that the member is not using Ilumya together with another biologic or targeted synthetic drug for the same indication.
05Concomitant use with another biologic or targeted synthetic drug for the same indication is considered experimental, investigational, or unproven.
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