Get Tremfya (Guselkumab) Covered by Aetna CVS Health in Ohio: Complete 2024 Guide with Forms and Appeal Scripts
Quick Answer: Do You Qualify for Tremfya Coverage?
Yes, if you meet Aetna's requirements: Adults with moderate-to-severe plaque psoriasis (PASI ≥10 or ≥10% body surface area), psoriatic arthritis, or ulcerative colitis who've tried preferred therapies or have clinical contraindications. First step today: Have your dermatologist, rheumatologist, or gastroenterologist complete Aetna's prior authorization form with TB screening results and documentation of prior therapy failures. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Process for Ohio Residents
- Required Documentation Checklist
- Cost Savings and Support Programs
- When to Escalate to State Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Mandatory for all Tremfya prescriptions | CVS Caremark Specialty: (866) 752-7021 | Aetna Policy |
| Step Therapy | Must try preferred biologics first (varies by condition) | Same as above | Aetna Criteria |
| Specialist Prescriber | Dermatologist (psoriasis), Rheumatologist (PsA), Gastroenterologist (IBD) | Provider directory | Clinical Policy |
| TB Screening | QuantiFERON or TST within 12 months | Lab results | FDA Label Requirements |
| Diagnosis Documentation | PASI score, % BSA affected, or validated disease activity | Medical records | Prior Auth Checklist |
Step-by-Step: Fastest Path to Approval
1. Confirm Your Diagnosis Meets Severity Thresholds
Who: Your specialist
What: Document moderate-to-severe disease:
- Plaque psoriasis: PASI ≥10 or ≥10% body surface area, plus candidacy for systemic therapy
- Psoriatic arthritis: Active disease with inadequate response to conventional DMARDs
- Ulcerative colitis: Moderately to severely active disease
Timeline: Same visit as initial consultation
2. Complete Required TB Screening
Who: Your doctor's office
What: Order QuantiFERON-TB Gold test (preferred over skin test)
Timeline: Results needed before starting Tremfya
Source: CDC TB Screening Guidelines
3. Document Step Therapy Requirements
Who: Your specialist
What: Record trials of preferred therapies:
- Psoriasis/PsA: Previous biologic or targeted synthetic (Humira, Otezla, etc.)
- IBD: May not require prior biologic failure (verify current criteria)
Timeline: Ongoing documentation in medical records
4. Submit Prior Authorization Request
Who: Your doctor's office
What: Complete Aetna's Tremfya PA form
How: Fax to CVS Caremark Specialty: (888) 267-3277
Timeline: Allow 30-45 days for standard review
5. Track Your Request
Who: You or your clinic
What: Call CVS Caremark at (866) 752-7021 for status updates
Timeline: Follow up after 2 weeks if no response
Tip: Keep copies of all submitted documents. Aetna must provide written notice of any denial with specific reasons.
Common Denial Reasons & How to Fix Them
| Denial Reason | How to Overturn | Required Documentation |
|---|---|---|
| "Insufficient disease severity" | Submit PASI score ≥10 or % BSA documentation | PASI scoring guide |
| "Step therapy not met" | Document prior biologic use or contraindications | Medical records showing drug trials and outcomes |
| "Missing TB screening" | Submit QuantiFERON results | Lab report dated within 12 months |
| "Not medically necessary" | Provide clinical rationale and guidelines | FDA labeling, specialty society guidelines |
| "Non-formulary drug" | Request formulary exception | CVS Exception Form |
Appeals Process for Ohio Residents
Level 1: Internal Appeal with Aetna
Deadline: 180 days from denial
How: Submit written appeal to address on denial letter
Timeline: 30 days for standard review, 72 hours for urgent
Required: Original denial letter, supporting medical records
Level 2: External Review through Ohio DOI
Deadline: 120 days after final Aetna denial
How: Submit Ohio External Review Request Form
Timeline: 30 days for standard, 72 hours for expedited
Cost: Free to you (Aetna pays)
Ohio DOI Contact: 1-800-686-1526
From our advocates: We've seen many Tremfya denials overturned at the external review level when patients included comprehensive documentation of disease severity and prior therapy failures. The key is showing you meet FDA-approved indications and have tried or can't use preferred alternatives.
Required Documentation Checklist
For Your Medical Team:
- Completed prior authorization form with specialist signature
- PASI score or disease activity measures
- TB screening results (QuantiFERON or TST)
- Documentation of prior therapies tried and outcomes
- Clinical notes supporting medical necessity
- ICD-10 diagnosis codes (L40.0 for plaque psoriasis)
For Your Records:
- Copy of insurance card and policy information
- Denial letters (if applicable)
- All submitted forms and supporting documents
- Timeline of communications with Aetna/CVS
Scripts & Templates
Phone Script for Calling Aetna Member Services:
"Hi, I'm calling about a prior authorization request for Tremfya for [patient name], member ID [number]. Can you please check the status and let me know what additional information might be needed? The request was submitted on [date] by Dr. [name]."
Peer-to-Peer Review Request:
"We'd like to request a peer-to-peer review for our Tremfya prior authorization denial. The reviewing physician should be a [dermatologist/rheumatologist/gastroenterologist] familiar with IL-23 inhibitor therapy. When can we schedule this discussion?"
Cost Savings and Support Programs
Janssen CarePath: Provides copay assistance and patient support
Website: janssencarepath.com
Eligibility: Commercial insurance patients (not government plans)
Patient Access Network Foundation: Grants for specialty medications
Website: panfoundation.org
State Programs: Ohio residents may qualify for additional assistance through local health departments
When to Escalate to State Regulators
Contact the Ohio Department of Insurance if:
- Aetna fails to respond within required timelines
- You're told external review isn't available (it is for medical necessity denials)
- The insurer requests inappropriate documentation
- You experience procedural violations
Ohio DOI Consumer Services: 1-800-686-1526
Online Complaint Form: insurance.ohio.gov
Frequently Asked Questions
Q: How long does Aetna's prior authorization process take?
A: Standard reviews take 30-45 days. Expedited reviews (with physician certification of urgency) are completed within 72 hours.
Q: What if Tremfya isn't on my formulary?
A: You can request a formulary exception using CVS's exception form. Include documentation of medical necessity and failure of covered alternatives.
Q: Can I get an expedited appeal in Ohio?
A: Yes, if your physician certifies that delay would seriously jeopardize your health. Both Aetna and Ohio's external review process offer expedited timelines.
Q: Do I need to try every covered drug first?
A: Not necessarily. If you have documented contraindications or previous failures with similar drug classes, these may satisfy step therapy requirements.
Q: What happens if I change doctors during the approval process?
A: Your new specialist will need to resubmit the prior authorization with their information. Keep all previous documentation to avoid starting over.
Q: Are there alternatives if Tremfya is denied?
A: Yes, other IL-23 inhibitors (Skyrizi), IL-17 inhibitors (Cosentyx, Taltz), and TNF inhibitors (Humira) may be covered. Discuss options with your specialist.
Q: How often do I need to renew prior authorization?
A: Typically annually. Aetna requires documentation of continued clinical response (such as maintained PASI improvement) for renewal.
Q: Can I appeal to federal agencies?
A: If you have an ERISA-governed employer plan, you may have additional federal appeal rights. Most individual and small group plans in Ohio follow state regulations.
About Counterforce Health
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that address specific coverage criteria. We help ensure that medically necessary treatments like Tremfya reach the patients who need them.
Whether you're navigating Aetna's step therapy requirements or preparing for Ohio's external review process, having the right documentation and strategy can make the difference between approval and denial. Counterforce Health specializes in this exact challenge—transforming complex payer requirements into clear action plans for better patient outcomes.
Sources & Further Reading
- Aetna Tremfya Prior Authorization Criteria (2024)
- Ohio Department of Insurance External Review Process
- CVS Caremark Formulary Exception Form
- Tremfya FDA Prescribing Information
- Janssen CarePath Patient Support
Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage decisions depend on individual circumstances, specific policy terms, and current payer criteria. Always consult with your healthcare provider about treatment decisions and contact your insurance company directly to verify current requirements. For personalized assistance with appeals in Ohio, consider consulting with a patient advocate or contacting the Ohio Department of Insurance consumer services.
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