J3245, Injection, tildrakizumab, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For initial therapy, submission of medical records (e.g., chart notes, laboratory values) documenting all of the following:
- Diagnosis of chronic moderate to severe plaque psoriasis.
- Greater than or equal to 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis.
- One of the following prior therapy documentation pathways: (a) Documentation of history of failure, contraindication, or intolerance to one of the specified topical therapies (Corticosteroids, Vitamin D analogs, Tazarotene, Calcineurin inhibitors, Anthralin, Coal tar) AND documentation of history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated or clinically significant adverse effects are experienced; OR (b) documentation that the patient has been previously treated with a biologic or targeted synthetic DMARD FDA-approved for plaque psoriasis and documentation of history of failure, contraindication, or intolerance to three of the preferred biologic products (list referenced).
Key Coverage Criteria
- Ilumya to be used as a self-administered, subcutaneous injection for the treatment of plaque psoriasis should be obtained under the pharmacy benefit, unless otherwise specified in the member's benefit plan documents. Exception: For members enrolled in UnitedHealthcare of California plans with a delegated provider group conducting the prior authorization review, the self-administered Ilumya may be obtained under the medical benefit.
- Ilumya (tildrakizumab) is proven for provider administration for the treatment of moderate to severe plaque psoriasis when the following criteria are met (initial therapy): Diagnosis of moderate to severe plaque psoriasis; and Physician attestation that the patient is unable to self-administer or there is no competent caregiver to administer the drug; physician must submit explanation; and Patient is not receiving Ilumya in combination with another targeted immunomodulator; and Dosing is in acco [...]
- Ilumya (tildrakizumab) is proven for provider administration for the treatment of moderate to severe plaque psoriasis when the following criteria are met (continuation of therapy): Documentation of positive clinical response to Ilumya therapy; and Physician attestation that the patient is unable to self-administer or there is no competent caregiver to administer the drug; physician must submit explanation; and Patient is not receiving Ilumya in combination with another targeted immunomodulator; [...]
- Ilumya (tildrakizumab) is medically necessary for provider administration for the treatment of moderate to severe plaque psoriasis when the following initial-therapy criteria are met: Diagnosis of chronic moderate to severe plaque psoriasis; and Greater than or equal to 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis; and One of the following: (a) Both of the following: History of failure, contraindication, or intolerance to one of the follo [...]
- Ilumya (tildrakizumab) indication per FDA: indicated for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
14 Active Policies
UHC-POL-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSIL-RX501.123, Tildrakizumab-asmn
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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