Does J3245 require prior authorization?

Yes, J3245 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J3245?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J3245`, Injection, tildrakizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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).
Physician attestation that the patient is unable to self-administer or there is no competent caregiver to administer the drug; physician must submit explanation.
Documentation that the patient is not receiving Ilumya in combination with another targeted immunomodulator.

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.
Indication: Adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

20 Active Policies

ARKBLUE-TILDRAKIZUMAB-ASMN-E-G-ILUMYA-72F288520D, Tildrakizumab-asmn (e.g., Ilumya)

FLORIDA_BLUE-FLBLUE-ILUMYA-TILDRAKIZUMAB-ASMN-001B899DC8, Ilumya (tildrakizumab-asmn)

BCBSLA-00651-6863AB44E3, 00651 tildrakizumab-asmn (Ilumya)

BCBSM-2092934-CBCBD93B20, NON AIM MEDICAL POLICY - TILDRAKIZUMAB-ASMN: ILUMYA (J3245)

BCBSM-2142721-F717372355, ILUMYA (TILDRAKIZUMAB-ASMN)

BCBSND-TILDRAKIZUMAB-ASMN-ILUMYA-497D965742, Tildrakizumab Asmn Ilumya

BCBSNJ-DRUGS-179-F21120282F, Tildrakizumab (Ilumya)

MODA-ILUMYA-8E2EB6D4B4, Ilumya (tildrakizumab-asmn)

IBX-MEDICARE-ADVANTAGE-MA08-098A-9F6ED072AA, Tildrakizumab-asmn (Ilumya)

IBX-COMMERCIAL-08-01-48B-575CED3EE9, Tildrakizumab-asmn (Ilumya)

UMR-POL-UMR-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

AMERIHEALTH-COMMERCIAL-08-01-48B-331266F9C8, Tildrakizumab-asmn (Ilumya)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-098A-B6C7B88389, Tildrakizumab-asmn (Ilumya)

BCBSTN-ee3ca8fb88, Tildrakizumab-asmn (Ilumya)

EVICORE-MEDICAL_DRUG-08980A2CF286, Ilumya (tildrakizumab-asmn)

OSCAR-ILUMYA-TILDRAKIZUMAB-ASMN-CG053-VER-9-80A5682B45, Ilumya (tildrakizumab-asmn) (CG053, Ver. 9)

UHC-COMM-MD-ILUMYA-TILDRAKIZUMAB-ASMN-COMMUNITY-PLAN-35FCB4EF99, Ilumya (Tildrakizumab-Asmn) – Community Plan Medical Benefit Drug Policy

UHC-POL-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

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J3245, Injection, tildrakizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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).
Physician attestation that the patient is unable to self-administer or there is no competent caregiver to administer the drug; physician must submit explanation.
Documentation that the patient is not receiving Ilumya in combination with another targeted immunomodulator.

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.
Indication: Adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

20 Active Policies

ARKBLUE-TILDRAKIZUMAB-ASMN-E-G-ILUMYA-72F288520D, Tildrakizumab-asmn (e.g., Ilumya)

FLORIDA_BLUE-FLBLUE-ILUMYA-TILDRAKIZUMAB-ASMN-001B899DC8, Ilumya (tildrakizumab-asmn)

BCBSLA-00651-6863AB44E3, 00651 tildrakizumab-asmn (Ilumya)

BCBSM-2092934-CBCBD93B20, NON AIM MEDICAL POLICY - TILDRAKIZUMAB-ASMN: ILUMYA (J3245)

BCBSM-2142721-F717372355, ILUMYA (TILDRAKIZUMAB-ASMN)

BCBSND-TILDRAKIZUMAB-ASMN-ILUMYA-497D965742, Tildrakizumab Asmn Ilumya

BCBSNJ-DRUGS-179-F21120282F, Tildrakizumab (Ilumya)

MODA-ILUMYA-8E2EB6D4B4, Ilumya (tildrakizumab-asmn)

IBX-MEDICARE-ADVANTAGE-MA08-098A-9F6ED072AA, Tildrakizumab-asmn (Ilumya)

IBX-COMMERCIAL-08-01-48B-575CED3EE9, Tildrakizumab-asmn (Ilumya)

UMR-POL-UMR-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care

SUREST-POL-SUREST-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

AMERIHEALTH-COMMERCIAL-08-01-48B-331266F9C8, Tildrakizumab-asmn (Ilumya)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-098A-B6C7B88389, Tildrakizumab-asmn (Ilumya)

BCBSTN-ee3ca8fb88, Tildrakizumab-asmn (Ilumya)

EVICORE-MEDICAL_DRUG-08980A2CF286, Ilumya (tildrakizumab-asmn)

OSCAR-ILUMYA-TILDRAKIZUMAB-ASMN-CG053-VER-9-80A5682B45, Ilumya (tildrakizumab-asmn) (CG053, Ver. 9)

UHC-COMM-MD-ILUMYA-TILDRAKIZUMAB-ASMN-COMMUNITY-PLAN-35FCB4EF99, Ilumya (Tildrakizumab-Asmn) – Community Plan Medical Benefit Drug Policy

UHC-POL-ilumya-tildrakizumab, Ilumya (Tildrakizumab-Asmn)

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`J3245`, Injection, tildrakizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3245`, Injection, tildrakizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3245, Injection, tildrakizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

J3245, Injection, tildrakizumab, 1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`J3245`, Injection, tildrakizumab, 1 mg

`J3245`, Injection, tildrakizumab, 1 mg