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

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

Aetna, a CVS Health company, updated its coverage policy for tildrakizumab-asmn (Ilumya) under CPB 1012 Aetna system. The policy governs medical necessity criteria for Ilumya in plaque psoriasis, billed primarily under HCPCS J3245 (injection, tildrakizumab, 1 mg). If your practice or health system handles dermatology billing for commercial Aetna members, this policy affects how you document and submit claims for one of the more commonly requested IL-23 inhibitors.

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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 (prescribing required); billing teams handling specialty pharmacy and infusion claims
Key Action	Confirm prior authorization documentation meets the updated step-therapy and BSA criteria before submitting J3245 claims

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Aetna Tildrakizumab Coverage Criteria and Medical Necessity Requirements 2026

The Aetna tildrakizumab-asmn coverage policy requires precertification for all participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277 to initiate. You can also submit a Statement of Medical Necessity (SMN) form through Aetna's Specialty Pharmacy Precertification portal.

Prescribing must come from a dermatologist — or the prescribing physician must document a consultation with one. This is a hard requirement. If your practice is multi-specialty or you're billing on behalf of a primary care provider who co-manages psoriasis, flag this now. A claim submitted without dermatology involvement will not survive a prior authorization review.

Initial Approval: Two Pathways

Aetna lays out two routes to medical necessity approval for Ilumya.

Pathway 1 — Prior Biologic or Targeted Synthetic Use: The member has previously used a biologic or targeted synthetic drug indicated for moderate to severe plaque psoriasis. Sotyktu (deucravacitinib) and Otezla (apremilast) are explicitly named as examples. There is no specific HCPCS code for Sotyktu or Otezla in the covered group — Aetna uses the prior-use history as documented evidence, not a code-based trigger.

Pathway 2 — Disease Severity Criteria: The member has not used a prior biologic or targeted synthetic, but meets severity thresholds. Aetna will consider Ilumya medically necessary when any of the following are true:

#	Covered Indication Copy
1	Crucial body areas are affected — hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas
2	At least 10% of body surface area (BSA) is affected
3	At least 3% BSA is affected AND the member has had an inadequate response or intolerance to phototherapy (UVB or PUVA, billed under CPT 96910, 96912, or 96913) OR pharmacologic treatment with methotrexate (J8610, J8611, J8612, J9250, J9255, J9260), cyclosporine (J7502, J7515, J7516), or acitretin

That 3% BSA pathway also accepts documented clinical reasons to avoid methotrexate, cyclosporine, and acitretin — a Appendix-referenced list in the full policy. If you're documenting this route, you need that Appendix language reflected in the clinical notes, not just a generic "contraindicated" notation.

Continuation of Therapy

Aetna's reimbursement for ongoing Ilumya therapy requires demonstrated response. The member must show either a reduction in BSA affected from baseline or improvement in signs and symptoms — itching, redness, flaking, scaling, burning, cracking, or pain. This applies to new members who are already on Ilumya when they join an Aetna plan, not just members who started on the drug under Aetna coverage.

Document both baseline and current status at every renewal. If your clinical notes at reauthorization don't reference baseline BSA or symptom severity, you're setting up a claim denial.

Tuberculosis Screening Requirement

Before initiating Ilumya, every member new to biologic or targeted synthetic therapy must have a documented negative TB test within the past 12 months. Aetna accepts a tuberculosis skin test (TST, billed as CPT 86580) or an interferon-gamma release assay (IGRA, billed as CPT 86480 or 86481).

If the TB screen is positive, the member needs further workup — including a chest X-ray (CPT 71045, 71046, 71047, or 71048) — to rule out active disease. Active TB is a hard stop. Latent TB requires treatment initiation before Ilumya can start.

Build TB screening confirmation into your prior auth checklist. Missing this documentation is an easy, avoidable denial.

Combination Biologic Restriction

Members cannot use Ilumya at the same time as any other biologic or targeted synthetic drug for the same indication. If your patient is on another IL-17, IL-23, or TNF inhibitor for psoriasis, concurrent use is not covered. Document single-agent status clearly in prior auth submissions.

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Aetna Tildrakizumab Exclusions and Non-Covered Indications

Aetna considers all indications outside of moderate to severe plaque psoriasis to be experimental, investigational, or unproven under CPB 1012. The policy does not enumerate specific excluded conditions — any use outside the covered plaque psoriasis criteria will not meet medical necessity under this policy. If you're seeing prescribers request Ilumya for anything outside plaque psoriasis, the auth will not go through — and a claim submitted without auth will deny on medical necessity grounds.

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Coverage Indications at a Glance

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Aetna Tildrakizumab Billing Guidelines and Action Items 2026

This is where the policy gets practical. The Ilumya billing guidelines under CPB 1012 have real teeth — and several spots where documentation gaps will produce denials.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Tildrakizumab Under CPB 1012

Covered HCPCS Codes (When Selection Criteria Are Met)

Code	Type	Description Copy
J3245	HCPCS	Injection, tildrakizumab, 1 mg

ICD-10-CM Diagnosis Codes

Note: The source policy lists all L40.x codes under the generic description "Psoriasis." Standard ICD-10-CM sub-descriptions are shown below for reference and are not part of the Aetna policy text.

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