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Coverage criteria policies

Tildrakizumab-asmn (Ilumya™)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Tildrakizumab-asmn (Ilumya) requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Tildrakizumab-asmn (Ilumya) is generally covered subject to the indications listed below when all of the following criteria are met, and per your plan documents.

Initial Authorization

  1. Prescribed by Dermatology; and
  2. Diagnosed with moderate to severe psoriasis defined as at least 10% body surface area (BSA), or crucial body area involvement (palmar/plantar, scalp, or genitals), or pustular psoriasis; and
  3. Patient has had a trial and failure (BSA involvement is not improved) of an appropriate regimen or intolerance or contraindications to concurrent use of at least two of the regimens below for at least 12 weeks:
    1. Topical corticosteroid therapy
    2. Phototherapy: at least 20-30 treatments given 2-3 times weekly
    3. Methotrexate 5mg-15mg weekly (GI intolerance requires trial of SC/IM methotrexate at 5mg-15mg weekly) in combination with folic acid supplementation
    4. Cyclosporine at a dose of at least 2.5 – 5mg/kg/day until disease control achieved
    5. Acitretin at a dose of at least 25mg daily; and
  4. Patient has tried and failed both Humira and Enbrel using the FDA-approved regimens for each for a duration of at least 3 months; and
  5. Ilumya will not be used in combination with another biologic medication; and
  6. Ilumya will be used at the FDA approved dosing regimen; and
  7. The treatment goals and monitoring plan are documented in the medical record.

Renewals

  1. Provider attests that they have seen the patient within the last fourteen months and the patient is benefiting from use of the medication; and
  2. Ilumya is prescribed within the FDA approved dosing regimen; and
  3. Ilumya will not be used in combination with another biologic medication.

Authorizations will be provided for 12 months.

Definitions

ILUMYA is an interleukin-23 antagonist indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:
HCPCS

Codes

Description

C9399

Unclassified drugs or biologicals (Hospital Outpatient Use ONLY)

J3245

Injection, tildrakizumab, 1 mg (effective 1/1/2019)

J3590

Unclassified biologics (use before 1/1/2019)

NDC

Codes

Description

47335017795

Ilumya 100 MG/ML SOSY

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for some, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Ilumya (prescribing information), Whitehouse Station, NJ, Merck & Co. Inc., March 2018.

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Policy activity

  • 05/07/2018 - Date of origin
  • 05/07/2018 - Effective date

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