Tildrakizumab-asmn (Ilumya) — CPB 1012 | AETNA Coverage Update

Aetna modified CPB 1012 for tildrakizumab-asmn (Ilumya) effective January 5, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated its coverage policy for tildrakizumab-asmn (Ilumya) under CPB 1012 Aetna system, with changes taking effect January 5, 2026. This Aetna Ilumya coverage policy governs prior authorization, medical necessity criteria, and continuation of therapy for plaque psoriasis (ICD-10 L40.0–L40.9). The primary reimbursement code is HCPCS J3245 (injection, tildrakizumab, 1 mg), and billing teams should review the updated criteria before submitting any new or renewal precertification requests.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Tildrakizumab-asmn (Ilumya) — CPB 1012
Policy Code	CPB 1012
Change Type	Modified
Effective Date	January 5, 2026
Impact Level	High
Specialties Affected	Dermatology; any provider prescribing or administering biologics for plaque psoriasis
Key Action	Audit all active and pending Ilumya prior authorization requests against the updated initial approval and continuation criteria before submitting new precertifications

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Aetna Ilumya Coverage Criteria and Medical Necessity Requirements 2026

Tildrakizumab-asmn billing starts with one non-negotiable: precertification is required for every Aetna member on every plan design. Call (866) 752-7021 or fax (888) 267-3277. No exceptions.

The updated coverage policy defines two separate tracks for initial approval. Your team needs to understand both before building out prior auth requests.

Track 1 — Prior biologic or targeted synthetic drug use. Aetna considers Ilumya medically necessary for adult members who have previously received a biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasis. This includes agents like Sotyktu (deucravacitinib) or Otezla (apremilast). No body surface area (BSA) threshold is required under this track. Prior use of an appropriate agent is enough.

Track 2 — BSA or body area criteria. Aetna also considers Ilumya medically necessary for adult members with moderate to severe plaque psoriasis when any of the following body surface area or body area criteria are met — regardless of prior biologic history:

#	Covered Indication Copy
1	Crucial body areas affected — hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas
2	At least 10% BSA affected — no step therapy required at this threshold
3	At least 3% BSA affected — but only if the member also has an inadequate response or intolerance to phototherapy (CPT 96910, 96912, or 96913) or conventional pharmacologic treatment with methotrexate (J8610, J8611, J8612, J9250, J9255, or J9260), cyclosporine (J7502, J7515, or J7516), or acitretin; OR has a documented clinical reason to avoid all three conventional agents (see Aetna's Appendix in CPB 1012)

This 3% BSA pathway is where most claim denials happen. If your documentation doesn't show prior conventional therapy failure or a clear contraindication to methotrexate, cyclosporine, and acitretin, the claim will not clear prior auth.

The TB Screening Requirement Is Mandatory for All Indications

Every Ilumya authorization — regardless of track — requires documented negative TB screening within 12 months of starting therapy. This applies to members who are new to biologics or targeted synthetic drugs. Acceptable tests include a tuberculosis skin test (TST, CPT 86580) or an interferon-gamma release assay (IGRA, CPT 86480 or 86481).

If the TB screen comes back positive, Aetna requires further workup to rule out active disease — which means a chest X-ray (CPT 71045, 71046, 71047, or 71048). Active TB disqualifies the member from receiving Ilumya. Latent TB requires treatment before starting Ilumya.

Build this TB documentation step into your precertification workflow. Missing it is an avoidable denial.

No Concurrent Biologic Use

Aetna will not approve Ilumya for any member currently using another biologic or targeted synthetic drug for the same indication. This is absolute. Document active medication lists carefully before submitting.

Prescribing Specialty Requirement

Ilumya must be prescribed by or in consultation with a dermatologist. If your practice is non-dermatology and you're managing a psoriasis patient on Ilumya, get that dermatology consultation documented before billing CPT 96372 for the injection.

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Aetna Ilumya Continuation of Therapy Criteria 2026

Continuation authorization has its own medical necessity standard. Aetna considers ongoing Ilumya therapy medically necessary when the member — including new members switching to Aetna coverage — is using the drug for moderate to severe plaque psoriasis AND shows a positive clinical response. That means either:

• Reduction in BSA affected from baseline, or
• Improvement in signs and symptoms from baseline — such as reduced itching, redness, flaking, scaling, burning, cracking, or pain

One of these two conditions must be met. Document both baseline status and current status clearly in every renewal request. Vague notes like "patient responding well" will not support medical necessity the way quantified BSA measurements or symptom scoring will.

The real issue here is baseline documentation captured at initiation. If your team didn't record baseline BSA or symptom severity when the patient started Ilumya, continuation renewals become much harder to defend. Establish that baseline now for any patient approaching renewal.

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Aetna Ilumya Exclusions and Non-Covered Indications

Aetna's position is direct: all indications for tildrakizumab-asmn other than moderate to severe plaque psoriasis in adults meeting the criteria above are considered experimental, investigational, or unproven.

There are no covered pediatric indications under this policy. There are no covered off-label uses. If your team sees Ilumya prescribed for anything other than adult plaque psoriasis, do not submit under J3245 expecting approval. It will deny.

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Coverage Indications at a Glance

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Aetna Ilumya Billing Guidelines and Action Items 2026

These steps apply to any practice billing J3245 for Aetna commercial plans.

Copy Action Items

If you're managing a high volume of psoriasis biologics across multiple payers and you're unsure how this update interacts with your current workflows, talk to your compliance officer or billing consultant before the January 5, 2026 effective date.

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CPT, HCPCS, and ICD-10 Codes for Tildrakizumab-asmn (Ilumya) Under CPB 1012

HCPCS Codes — Covered When Selection Criteria Are Met

Code	Description Copy
J3245	Injection, tildrakizumab, 1 mg

HCPCS Codes — Related Agents (Prior Therapy Documentation)

These codes support documentation of prior or conventional therapy. They are not covered codes for Ilumya itself but appear in CPB 1012 as relevant to step therapy requirements.

CPT Codes — Related Procedures

Key ICD-10-CM Diagnosis Codes

Note: Aetna's CPB 1012 lists the full L40 family but coverage is specifically for moderate to severe plaque psoriasis — most commonly billed under L40.0. Confirm ICD-10 specificity against your clinical documentation before billing. L40.7 does not appear as a standalone billable code in this policy and is not listed above.

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