Medicare does cover Ilumya. Because the injection has to be given by a healthcare provider, it falls under Medicare Part B as a physician-administered drug rather than under Part D. After you meet the annual Part B deductible, you owe 20% of the Medicare-allowed amount for each dose, and a Medigap policy can reduce that share to nothing.
Why Ilumya Is a Part B Drug, Not Part D
Medicare splits drug coverage by who administers the medication. Pills and self-injected pens generally go through Part D. Drugs that require a clinician to administer them go through Part B. Ilumya’s FDA labeling states it “should only be administered by a healthcare provider,”1DailyMed. Ilumya Prescribing Information which puts it on the Part B side of that line.2Ilumya. ILUMYA and Medicare Part B
That classification matters because it changes how you pay. Part D drugs run through a plan formulary with copay tiers and, for some patients, deductibles and coverage phases. Part B drugs use a single coinsurance percentage against the Medicare-allowed amount, and Medigap plans can pick up that share directly. For competing IL-23 biologics used in psoriasis, coverage lands differently: Skyrizi is a self-administered pen covered under Part D,3AbbVie. Skyrizi Coverage and Access and Tremfya can fall under either Part B or Part D depending on the route and setting.4Aetna. Tremfya IV Aetna Medicare Part B Drug Criteria Some dermatologists treat Ilumya’s clean Part B status as a benefit when transitioning patients onto Medicare, because it sidesteps the Part D formulary entirely.5Dermatology Times. Tailoring Biologic Options in Medicare-Age Patients With Plaque Psoriasis
What You’ll Pay With Original Medicare
Standard Part B cost-sharing works in two steps. First, you pay the annual Part B deductible, which is $283 in 2026.6CMS. 2026 Medicare Parts B Premiums and Deductibles After that, you owe 20% coinsurance on the Medicare-allowed amount for each dose.
That allowed amount is not the drug’s list price. CMS pays providers based on Average Sales Price plus 6%, updated every quarter.7Ilumya Pro. ILUMYA Billing and Coding Guide Ilumya is billed under HCPCS code J3245 in 1 mg units. One billing resource listed the Medicare payment limit for Q2 2026 at about $118.20 per unit, with a coinsurance amount of about $23.64 per unit.8Buy and Bill. Ilumya J3245 A 100 mg dose is billed as 100 units.
The Inflation Reduction Act adds a second layer. Since April 2023, when a Part B drug’s price rises faster than inflation, beneficiary coinsurance is calculated against a lower, inflation-adjusted amount rather than the full price.9KFF. Explaining the Prescription Drug Provisions in the Inflation Reduction Act Whether Ilumya is currently on that rebate list depends on its price history against a 2021 baseline.
How Medigap Can Bring Your Cost to Zero
The manufacturer’s own materials state that “most people with Medicare Part B coverage could pay $0 for Ilumya” when they also carry supplemental insurance.10Ilumya. ILUMYA and Medicare Part B Guide That refers to Medigap policies, which private insurers sell to fill the gaps in Original Medicare.
Medigap Plans A, B, C, D, F, G, and M pay 100% of Part B coinsurance. Plan N covers it with small copays on certain visits. Plans K and L cover 50% and 75%, respectively.11Medicare.gov. Compare Medigap Plan Benefits So a Plan G enrollee would pay the $283 Part B deductible once for the year and nothing further for Ilumya doses after that.12BCBS of North Dakota. Medicare Supplement Plan G 2026
One eligibility note: Plans C and F are closed to anyone who first became eligible for Medicare on or after January 1, 2020.11Medicare.gov. Compare Medigap Plan Benefits Newer enrollees looking for full coinsurance coverage typically land on Plan G or Plan N.
Medicare Advantage: Prior Authorization and Step Therapy
Medicare Advantage (Part C) plans must cover what Original Medicare covers, but they set their own prior authorization and step therapy rules. CMS has not issued a National or Local Coverage Determination for tildrakizumab, so plans have broad discretion.13UnitedHealthcare. Ilumya Tildrakizumab Coverage Policy Expect to see requirements like these:
- CareSource, administered through Express Scripts, requires a three-month trial of a traditional systemic agent such as methotrexate, cyclosporine, or acitretin, or a three-month trial of PUVA phototherapy. Prior use of another biologic for psoriasis or a documented contraindication to methotrexate satisfies the step.14CareSource. Medicare Multi-Policy Pharmacy Ilumya
- Aetna Medicare grants an initial 12-month authorization for moderate-to-severe plaque psoriasis and requires documented clinical benefit for renewal.15Aetna. Ilumya Aetna Medicare Part B Drug Criteria
- BCBS of Michigan (Medicare Plus Blue) classifies Ilumya as nonpreferred and requires a documented trial and failure of preferred infliximab and ustekinumab products first.16BCBSM. Changes to Step Therapy Requirements for Some Medical Benefit Drugs
- Devoted Health treats Ilumya as a Step 2 drug, requiring a Step 1 agent such as Entyvio, Simponi Aria, or IV Tremfya first, with exceptions for ineffectiveness, medical inappropriateness, or recent use of Ilumya itself.17Devoted Health. 2025 Step Therapy List Part B Drugs
Most plans also require that a dermatologist prescribe or consult on the treatment, and none permit concurrent use of another biologic for the same condition.14CareSource. Medicare Multi-Policy Pharmacy Ilumya Continuation typically hinges on documented improvement in measures like body surface area, erythema, itching, or pain.
The Manufacturer Copay Card Does Not Apply to Medicare
Sun Pharmaceutical runs a copay program that reduces patient cost to $0 per dose, but it is limited to commercially insured patients. The program is “not valid for patients if prescription is paid for by any state or federally funded healthcare program, including but not limited to Medicare, Medicaid, VA, DOD, or TRICARE.”18Ilumya. ILUMYA Savings
The manufacturer’s Patient Assistance Program can provide Ilumya at no cost to uninsured or functionally underinsured patients, but claims cannot be submitted to any government program, and patients with secondary Medicaid or a Low-Income Subsidy are excluded.18Ilumya. ILUMYA Savings For Medicare patients, that leaves Medigap or Advantage plan cost-sharing as the actual route to a low out-of-pocket cost. The ILUMYA SUPPORT program still offers benefits investigation and non-financial help through 855-445-8692.19Ilumya. Help From Our Team
What Coverage Looks Like in Practice
Ilumya is FDA-approved for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. The dose is 100 mg by subcutaneous injection at weeks 0 and 4, then every 12 weeks after that.20FDA. Ilumya Prescribing Information After the two loading doses, that works out to about five clinic visits a year, which clinicians treating older patients have cited as easier to keep than schedules requiring more frequent injections.5Dermatology Times. Tailoring Biologic Options in Medicare-Age Patients With Plaque Psoriasis
Before starting therapy, patients must be screened for tuberculosis. There is no generic or biosimilar version of Ilumya on the market.21Fair Square Medicare. Does Medicare Cover Ilumya If you have Original Medicare plus a Medigap policy that covers Part B coinsurance, your cost for the year is usually limited to the annual Part B deductible. If you have a Medicare Advantage plan, contact the plan before your first dose to confirm its prior authorization requirements and any step therapy you’ll need to complete first.