Is Ilumya Covered By Medicare

Clearer Skin That Lasts With Fewer Treatments

Groundbreaking Hope for Moderate-to-Severe Plaque Psoriasis Patients

ILUMYAÂ® can give you clearer skin that lasts with fewer treatments than most other biologic medicines. With ILUMYAÂ®, you receive only 4 doses a year after 2 initial doses.

ILUMYAÂ® is given by a healthcare provider in the office. This means that after your initial doses, you should plan to see your dermatologist every 12 weeksâeven when your skin starts to look better.

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Subject to terms and conditions. Must be enrolled in ILUMYA SUPPORTÂ® to qualify. Not valid for patients without commercial insurance coverage or if prescription is paid for by any state- or federally funded healthcare program, including but not limited to Medicare, Medicaid, VA, DOD, or TRICARE. Available to US, Guam, Virgin Islands, or Puerto Rico residents only. See the full terms and conditions for ILUMYA SUPPORTÂ® programs at

The ILUMYA SUPPORT Lighting the WayÂ® program text messaging is valid with most major US carriers. There is no fee payable to Sun Pharma to receive text messages however, your carrierâs message and data rates may apply. Participants may receive an average of 5 messages per month during the course of this program. You may unsubscribe from the Program at any time by texting STOP. For help, text HELP or contact your mobile carrier.

*Subject to terms and conditions. Must be enrolled in ILUMYA SUPPORTÂ® to qualify. Not valid for patients without commercial insurance coverage or if prescription is paid for by any state- or federally funded healthcare program, including but not limited to Medicare, Medicaid, VA, DOD, or TRICARE. Available to US, Guam, Virgin Islands, or Puerto Rico residents only. See the full terms and conditions for ILUMYA SUPPORTÂ® programs at

Ilumya Support Patient Access For Commercial And Medicare Part B Patients

About This Series

ILUMYA is indicated for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Learn about ILUMYA in this four-part series:

Video 1: See how ILUMYA works
Video 2: Long-term efficacy and safety data from ILUMYA clinical trials

Video 3: Patients types that may be a great fit for ILUMYA
Video 4: ILUMYA SUPPORT patient access for commercial and Medicare Part B patients

Please see the full Prescribing Information available at ilumyapro.com

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Forms For State Mandates

Colorado authorization form

The use of this form is mandated for prior authorization requests concerning commercial fully insured members who:

Reside in the state of Colorado and/or

Whose prescription drug coverage was sold in the state of Colorado

Illinois authorization request form

Physicians and healthcare practitioners in Illinois should use this form to submit authorization requests for their Humana commercial fully insured covered patients and residents. Please complete the form and submit it to Humana by following the instructions on the form.

Kentucky Medicaid Authorization Form

Physicians and health care practitioners in Kentucky may use this form to submit authorization requests for their Humana-Medicaid covered patients. Please complete the form and submit it to MedImpact by following the instructions on the form.

New Mexico authorization request form

Physicians and health care practitioners may use this form to submit authorization requests for their New Mexico Humana-Covered patients. Please complete the form and submit it to Humana by following the instructions on the form.

Texas authorization form

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Tips For The Journey:

Have a flare that itches and burns? Try a cold compress.

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Thank you for signing up to learn more about ILUMYAÂ®. Keep a look out for more information coming to you soon.

For more information, call us at .

Prescriber Quick Reference Guide

This guide helps prescribers determine which Humana medication resource to contact for prior authorization, step therapy, quantity limits, medication exceptions, appeals, prior authorization and claims. It also provides phone, fax and web contact information.

Puerto Rico Prior Authorization Requests

Prescribers should submit these requests to the Puerto Rico Medication Intake Team by fax at 1-800-594-5309 or 1-800-658-9457 .

Prescribers with questions about the prior authorization process for professionally administered drugs should call 1-866-488-5995 for Medicare requests and 1-800-314-3121 for commercial requests. Assistance is available Monday through Friday, 8:30 a.m. to 5:30 p.m. local time.

Experimental And Investigational Or Not Medically Necessary

Does Medicare Cover Biologic Treatment for Moderate-to-Severe Plaque Psoriasis?

Aetna considers the use of targeted immune modulators in combination with other targeted immune modulators for plaque psoriasis , certolizumab , etanercept , guselkumab infliximab , risankizumab-rzaa , secukinumab , tildrakizumab-asmn , and ustekinumab ) experimental and investigational because of insufficient evidence of effectiveness.

Aetna considers combination use of two or more targeted immune modulators for psoriatic arthritis experimental and investigational because of insufficient evidence of effectiveness.

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Pay As Little As $0 For Ilumya*

Letâs get started

With the ILUMYAÂ® Copay Card, eligible patients with commercial insurance may pay as little as $0* for ILUMYAÂ®. If you do not qualify for the copay card, there are still savings options available to youâlike the Early Access Program.â

Answer the questions below to save on your prescription and join ILUMYA SUPPORT Lighting the WayÂ® to take advantage of all that ILUMYAÂ® has to offer! In order to submit this form, you must be prescribed ILUMYAÂ® and be 18 years of age or older.

Are you a healthcare professional enrolling on behalf of a patient? Access copay information here.

Patient Support To Keep You Going

ILUMYAÂ® has the type of support to get you going and keep you going. Start by talking with your healthcare provider about personal supportâthis includes ensuring that your insurance covers your moderate-to-severe plaque psoriasis treatment and checking your eligibility for financial assistance through ILUMYA SUPPORT Lighting the WayÂ®.

Ask your dermatologist to submit your ILUMYA SUPPORT Lighting the WayÂ® enrollment form so that you can receive all the benefits available to you.

CONFIRM

We will confirm if your prescription is covered by your insurance provider and if you are qualified for ILUMYAÂ® financial support programs.

PREPARE

Prepare for a call from your ILUMYA SUPPORTÂ® team or your specialty pharmacy to receive your coverage benefits.

SCHEDULE

Schedule an appointment with your dermatologist for your first dose. Because ILUMYAÂ® is a biologic medicine that is injected in the office by a medical professional, it is covered by Medicare Part B as a medical benefit.

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Dermatologist Shares Tips For Navigating Medicare And Securing Biologics Coverage For Psoriasis

People living with psoriasis who are eligible for Medicare may want to consider biologic treatment when selecting Part B coverage, according to dermatologist Dr. Jerry Bagel.
It’s a good idea to inquire about a staff biologics coordinator when looking for a prospective health care team.
Secondary insurance and financial assistance from drug manufacturers can help cover additional costs.

With open enrollment for Medicare now underway, people living with psoriasis who are securing or adjusting their coverage may want to factor biologics into their coverage plan. Such was the guidance from dermatologist Dr. Jerry Bagel, a board member of the National Psoriasis Foundation , during a recent NPF webinar on biologics and Medicare Part B coverage.

During the webinar, Dr. Bagel also director of the Psoriasis Treatment Center of New Jersey discussed the effectiveness of biologic drugs for treating psoriasis and how they can be covered by Medicare Part B insurance.

Typically used for moderate to severe psoriasis, biologics are administered through an injection or IV infusion at a doctors office or clinic. As such, they are classified as medical care and will often be covered under Medicare Part B. Most other prescription medications that are administered outside of a medical setting are considered for coverage by Medicare Part D insurance.

Below are some tips from Dr. Bagel for navigating Medicare Part B biologic coverage.

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When Affordability Isnt A Possibility

Navigating Medicare costs when an expensive treatment is your best option.

Every October,millions of Americans begin shopping for a Medicare Part D plan to cover their prescription drug costs. When choosing a plan, most people want to ensure their treatments are covered and affordable. But for those taking expensive treatments through Medicare Part D, affordable is not always an option.

That was the case for Wayne Hauber of Iowa. âThe act of retiring made my biologic unaffordable and my costs unpredictable. Medicare Part D plans and biologics do not mix well!â Like many others with psoriatic disease, Wayne learned firsthand how out-of-pocket costs can skyrocket when switching to Medicare from a commercial insurance plan. This is because, unlike many forms of health insurance, Medicare Part D does not have an annual out-of-pocket maximum, leaving patients on the hook for thousands of dollars a year.

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The American Hospital Association has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

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Financial Support To Get You Going

Learn about ILUMYAÂ® low-or no-cost options based on your type of insurance.

Most people with commercial insurance pay $0 for ILUMYAÂ® for their first 2 years through the Early Access Program. After that, they typically still pay as little as $0 for each dose.

If you need help affording your prescription, these programs are available to you.

$0
ILUMYAÂ® EARLY ACCESS PROGRAM

If you have commercial insurance, you will be automatically enrolled in this program and are eligible to receive ILUMYAÂ® for free for up to 2 years.â
$0
ILUMYAÂ® COPAY PROGRAM

Patients with commercial insurance may sign up for affordable treatment through the ILUMYAÂ® Copay Program. Eligible patients may pay as little as $0* per dose.

See full Terms and Conditions for these savings programs.

Most people with Medicare Part B coverage could pay $0 for ILUMYAÂ®

MOST PEOPLE WITH MEDICARE PART B COVERAGE COULD PAY $0 FOR ILUMYAÂ®

With our Patient Assistance Program, you could be eligible to receive ILUMYAÂ® at no cost

Individual results may vary.

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For Medicare Advantage Plans That Do Not Offer Prescription Drug Coverage

Ilumya and Tremfya, for the indication listed below:

Plaque Psoriasis

Are not covered for new starts, unless the member meets ANY of the following:
Inadequate response to a trial of Avsola or Remicade
Intolerable adverse event to Avsola or Remicade

Avsola or Remicade is contraindicated for the member.

Tremfya, for the indication listed below:

Psoriatic arthritis

Is not covered for new starts, unless the member meets ANY of the following:
Inadequate response to a trial of Avsola, Remicade, or Simponi Aria

Intolerable adverse event to Avsola, Remicade, or Simponi Aria
Avsola, Remicade, or Simponi Aira is contraindicated for the member.

Examples Of Clinical Reasons To Avoid Pharmacologic Treatment With Methotrexate Cyclosporine Or Acitretin

Clinical diagnosis of alcohol use disorder, alcoholic liver disease, or other chronic liver disease

Cannot be used due to risk of treatment-related toxicity

Pregnancy or currently planning pregnancy

Significant comorbidity prohibits use of systemic agents

Table: Brands of Targeted Immune Modulators and FDA-approved Indications:

Brand Name

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Pretreatment Evaluation For Tuberculosis

Evaluate patients for tuberculosis infection prior to initiating treatment with ILUMYA. Do not administer ILUMYA to patients with active TB infection. Initiate treatment of latent TB prior to administering ILUMYA. Consider anti-TB therapy prior to initiation of ILUMYA in patients with a past history of latent or active TB in whom an adequate course of treatment cannot be confirmed. Patients receiving ILUMYA should be monitored closely for signs and symptoms of active TB during and after treatment.

Criteria For Initial Approval

Moderate to severe plaque psoriasis

Aetna considers targeted immune modulators adalimumab , certolizumab , etanercept , guselkumab infliximab , risankizumab-rzaa , secukinumab , tildrakizumab-asmn , or ustekinumab medically necessary for the treatment of moderate-to-severe plaque psoriasis who meet the following:

For members who have previously received apremilast or a biologic indicated for the treatment of moderate-to-severe plaque psoriasis or

For treatment of moderate-to-severe plaque psoriasis when any of the following criteria is met:

Crucial body areas are affected or

At least 10% of the body surface area is affected or

At least 3% of the BSA is affected and the member meets any of the following criteria:

Member has had an inadequate response or intolerance to either phototherapy or pharmacologic treatment with methotrexate, cyclosporine, or acitretin or

Member has a clinical reason to avoid pharmacologic treatment with methotrexate, cyclosporine, and acitretin .

Active psoriatic arthritis

Aetna considers targeted immune modulators abatacept , adalimumab , certolizumab , etanercept , guselkumab , infliximab , golimumab , risankizumab-rzaa , secukinumab , and ustekinumab medically necessary for the treatment of active psoriatic arthritis .

Aetna considers all other indications as experimental and investigational .

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Look For A Biologics Coordinator

Dr. Bagel encouraged people living with psoriasis to ask prospective dermatologists if they typically prescribe biologics and whether they have a biologics coordinator on staff. A biologics coordinator is someone who advocates for people taking biologics when negotiating with insurance companies. They are essential, said Dr. Bagel.

Working with a medical team that has a biologics coordinator on staff will help a person get insurance coverage for biologic medications and reduce ones out-of-pocket costs, Dr. Bagel explained.

For Medicare Advantage Plans That Offer Prescription Drug Coverage