| Anthem Blue Cross (HMO, PPO, EPO) |
| Ilumya (tildrakizumab-asmn) |
| Drugs for the Skin : Drugs for the Skin |
- Prior Authorization: Psoriasis (PsO):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 18
Duration: 1 year(s)
- Quantity Limit: 1 syringe per 84 day(s).
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on drug coverage click HERE;
- Step Therapy: Psoriasis (PsO):
ST Multiple Brands
- Psoriasis (PsO):
Age Requirement: >= 18
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
TB Test required: Yes
History of Plaque Psoriasis: N/A
Overall % of Body Surface For Initiation: 5
Overall % of Body Surface For Initiation With Sensitive Areas: Unspecified
Psoriasis Classification: Moderate-Severe
Sensitive Area BSA Percent override: Yes
- PA Applies
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