Ilumya — Medical Mutual
Other inflammatory conditions
Preferred products
- Enbrel
- adalimumab-adbm
- adalimumab-adaz
- adalimumab-ryvk
- Cyltezo
- Simlandi
- Taltz
- Otezla
- Skyrizi SC
- Ustekinumab SC Products (Selarsdi, Stelara, ustekinumab-ttwe, Yesintek)
- Tremfya SC
- Omvoh SC
- Zymfentra
- Velsipity
- Sotyktu
Initial criteria
- Patient must meet the standard Inflammatory Conditions Prior Authorization Policy criteria specific to each drug and indication
- Trials of preferred products are required before approval of non-preferred products according to step therapy tables
- Documentation required for verification of product trial unless claim history is available
- For continuation, must show prescription claims history of ≥90 out of prior 130 days, or prescriber verification of ≥90 days paid use
Reauthorization criteria
- For continuation therapy, patient must still meet standard policy criteria
- Prescription claims history must verify continued use (≥90 days supply in past 130 days) OR prescriber verification of continued use
- Other disease-specific step therapy and exception conditions apply (e.g., failure of required number of preferred therapies, or medical exception such as contraindication or comorbidity)
Approval duration
6 months initial; 3 months for plaque psoriasis and hidradenitis suppurativa; 1 year continuation