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Ilumya (tildrakizumab-asmn) — United Healthcare

Plaque Psoriasis

Preferred products

  • Preferred adalimumab products
  • Cimzia (certolizumab)
  • Cosentyx (secukinumab)
  • Enbrel (etanercept)
  • Skyrizi (risankizumab)
  • Sotyktu (deucravacitinib)
  • Preferred ustekinumab products
  • Tremfya (guselkumab)

Initial criteria

  • 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
  • History of failure to one topical therapy unless contraindicated or clinically significant adverse effects (document drug, date, duration). Examples: Corticosteroids (betamethasone, clobetasol, desonide), Vitamin D analogs (calcitriol, calcipotriene), Tazarotene, Calcineurin inhibitors (tacrolimus, pimecrolimus), Anthralin, Coal tar
  • History of failure to a 3 month trial of methotrexate at maximally indicated dose unless contraindicated or clinically significant adverse effects (document date and duration). For Connecticut, Kentucky, and Mississippi business only, a 30‑day trial is required
  • OR patient previously treated with a targeted immunomodulator FDA-approved for plaque psoriasis as documented by claims history or medical records (Document drug, date, and duration) [e.g., Cimzia (certolizumab), adalimumab, Otezla (apremilast), Skyrizi (risankizumab), ustekinumab, Tremfya (guselkumab), Enbrel (etanercept)]
  • History of failure, contraindication, or intolerance to three of the following preferred products (document drug, date, and duration): one preferred adalimumab product, Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Skyrizi (risankizumab), Sotyktu (deucravacitinib), one preferred ustekinumab product, Tremfya (guselkumab)
  • Patient is not receiving Ilumya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]
  • Prescribed by or in consultation with a dermatologist

Reauthorization criteria

  • Documentation of positive clinical response to Ilumya therapy
  • Patient is not receiving Ilumya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Tremfya (guselkumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]

Approval duration

12 months