Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Initial Criteria
Tildrakizumab (Ilumya) may be considered medically necessary when the following criteria are met:
-
The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route);
and
- The individual must have failed a 3-month trial of a TNF inhibitor [i.e., infliximab, certolizumab pegol, etanercept, adalimumab] and an Interleukin (IL)-17A Inhibitor [i.e., ixekizumab (Taltz), secukinumab (Cosentyx)] and an Interleukin (IL)-17A and IL-17F inhibitor [i.e., bimekizumab-bkzx (Bimzelz)], as evidenced by paid claims or printouts.
Reauthorization Criteria
The continues use of tildrakizumab (Ilumya) may be considered medically necessary when
ALL
of the following criteria are met:
-
The individual has previously been approved for tildrakizumab (Ilumya) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy;
and
- The individual must continue to meet applicable initial criteria.
The use of tildrakizumab (Ilumya) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
