By Counterforce Health Team in Tremfya (guselkumab) —

Get Tremfya (Guselkumab) Covered by Blue Cross Blue Shield in California: Prior Authorization Forms, Appeals, and Success Strategies

Answer Box: Fastest Path to Tremfya Approval

Tremfya (guselkumab) requires prior authorization from Blue Cross Blue Shield in California for plaque psoriasis and psoriatic arthritis. First step: Have your dermatologist/rheumatologist complete TB screening and document prior therapy failures. Submit PA via fax (888-697-8122) or CoverMyMeds ePA. Standard approval takes 24-72 hours. If denied, file internal appeal within 180 days, then request California's Independent Medical Review (IMR) for a 73% chance of overturn for specialty drugs.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Clinical Requirements & TB Screening
  4. Specialty Pharmacy Requirements
  5. Common Denial Reasons & Fixes
  6. Appeals Process in California
  7. Costs & Financial Assistance
  8. Renewal & Reauthorization
  9. FAQ: Most Common Questions
  10. Sources & Further Reading

Coverage Basics

Is Tremfya Covered by Blue Cross Blue Shield in California?

Yes, Tremfya (guselkumab) is covered by Blue Shield of California as a specialty medication for:

  • Moderate-to-severe plaque psoriasis (adults ≥18)
  • Psoriatic arthritis (diagnosed by rheumatologist)

Important: Tremfya for Crohn's disease or ulcerative colitis is currently considered off-label under Blue Shield of California's policy and typically requires separate medical necessity review.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing PA Forms Blue Shield CA
Formulary Status Specialty tier drug 2024 Specialty Drug List Blue Shield CA
Step Therapy Must fail ≥1 systemic therapy Tremfya Policy Blue Shield CA
Specialty Pharmacy Required dispensing channel Member ID card/portal Blue Shield CA
TB Screening Mandatory before starting Provider clinical notes Standard biologic protocol

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Staff)
  2. Complete TB Screening (Prescriber)
    • Order TB test (IGRA or TST) plus chest X-ray if indicated
    • Document results in clinical notes
    • Timeline: 1-3 days for results
  3. Gather Documentation (Clinical Staff)
    • Prior therapy history with specific drugs, doses, duration, failure reasons
    • PASI score ≥10, BSA ≥3%, or sensitive area involvement
    • Timeline: 30 minutes
  4. Submit PA Request (Prescriber/Staff)
  5. Route to Specialty Pharmacy (After Approval)
    • Send prescription to plan-contracted specialty pharmacy
    • Include PA approval number
    • Timeline: 2-5 business days for delivery

Clinical Requirements & TB Screening

Blue Shield of California Tremfya Criteria

For Plaque Psoriasis:

  • Age ≥18 years
  • Prescribed by dermatologist or rheumatologist
  • Disease severity (one of):
    • PASI ≥10, OR
    • BSA ≥3%, OR
    • Sensitive area involvement (face, hands, feet, groin)
  • Prior therapy failure/intolerance to ≥1 of:
    • Methotrexate
    • Cyclosporine (Neoral)
    • Acitretin (Soriatane)
    • PUVA or UVB phototherapy
  • Not used with other targeted biologics or Otezla

Dosing Limits:

  • Maximum: 100 mg SC at weeks 0, 4, then every 8 weeks
  • Initial coverage: 24 weeks
  • Maintenance: yearly reauthorization
Clinician Corner: Include exact ICD-10 codes (L40.50-L40.59 for plaque psoriasis) and document specific PASI scores or BSA percentages. Generic statements like "moderate psoriasis" often trigger denials.

TB Screening Requirements

While not explicitly detailed in the Tremfya policy, standard biologic protocols require:

  • Baseline TB screening (IGRA or TST)
  • Chest imaging if TB test positive
  • Documentation that patient has no active TB or serious infections
  • Treatment plan for latent TB if applicable

Include TB screening results, date, and interpretation in your PA submission.

Specialty Pharmacy Requirements

Tremfya must be dispensed through a Blue Shield-contracted specialty pharmacy. Common networks include:

  • CVS Specialty
  • Accredo
  • Express Scripts Specialty

To find your required pharmacy:

  1. Check member's ID card for specialty pharmacy information
  2. Call Blue Shield member services: (800) 535-9481
  3. Use the formulary lookup tool
Note: "Buy-and-bill" through office pharmacies is generally not covered under the pharmacy benefit.

Common Denial Reasons & Fixes

Denial Reason How to Fix Documents Needed
"Insufficient disease severity" Submit PASI scores, BSA measurements, photos Dermatologist assessment with objective scores
"Must try preferred agent first" Document contraindications or prior failures Chart notes showing specific drug trials and outcomes
"Missing TB screening" Complete and submit results Lab reports with dates and interpretation
"Non-formulary drug" File formulary exception request Medical necessity letter citing contraindications to preferred agents
"Concurrent biologic use" Confirm no other targeted therapies Current medication list and prescriber attestation

Appeals Process in California

Internal Appeal with Blue Shield

Deadline: 180 days from denial date How to file:

  • Complete grievance form
  • Include denial letter and supporting documentation
  • Submit via member portal or fax to 888-697-8122

Timeline: 30 days for standard review, 72 hours for urgent cases

California Independent Medical Review (IMR)

If internal appeal is denied, California residents can request IMR through the Department of Managed Health Care (DMHC).

Success Rate: Specialty drug appeals have approximately 73% overturn rate in California's IMR process.

How to request IMR:

  1. File online at healthhelp.ca.gov
  2. Call DMHC Help Center: (888) 466-2219
  3. Submit within 180 days of final internal denial

Timeline: 30-45 days for standard IMR, 72 hours for expedited

From our advocates: We've seen multiple Tremfya denials overturned through California's IMR when appeals included detailed specialist letters explaining why conventional therapies failed and why Tremfya was medically necessary. Strong documentation significantly improves success rates.

Costs & Financial Assistance

Typical Cost Structure

Tremfya is classified as a specialty tier medication, typically requiring:

  • 20-30% coinsurance up to plan maximum, OR
  • High fixed copay ($100-500+ per fill)

Exact costs depend on your specific Blue Shield plan design.

Financial Assistance Options

  1. Janssen CarePath Savings Program
    • Eligible patients may pay as little as $5 per dose
    • JanssenCarePath.com
    • Not available for Medicare/Medicaid patients
  2. Patient Assistance Programs
    • Income-based free medication for qualifying patients
    • Apply through Janssen CarePath
  3. California State Programs
    • Covered California premium assistance
    • Medi-Cal for eligible low-income residents

Renewal & Reauthorization

Yearly Reauthorization Requirements

Blue Shield requires annual renewal for continued Tremfya coverage. Submit documentation showing:

  • Continued diagnosis and appropriate prescriber
  • Clinical improvement from baseline:
    • Improved PASI scores
    • Reduced BSA involvement
    • Symptom and quality-of-life improvements
  • No concurrent targeted biologics or Otezla
  • Absence of serious infections including TB

Use the same PA submission process with "Renewal" indicated on forms.

FAQ: Most Common Questions

Q: How long does Blue Shield PA take in California? A: Standard PA decisions are typically made within 24-72 hours. Urgent cases may be expedited to same-day or next-day review.

Q: What if Tremfya is non-formulary on my plan? A: Request a formulary exception by documenting medical necessity and contraindications to preferred alternatives. Include specialist letter of medical necessity.

Q: Can I request an expedited appeal? A: Yes, if waiting for standard review would seriously jeopardize your health. Both Blue Shield internal appeals and California IMR offer expedited review options.

Q: Does step therapy apply if I failed treatments outside California? A: Yes, document prior therapy failures regardless of where they occurred. Include specific drug names, doses, duration, and reasons for discontinuation.

Q: What if my dermatologist isn't available for peer-to-peer review? A: Request the specific date/time for peer-to-peer and arrange coverage with another qualified specialist if needed. Document the clinical rationale thoroughly in advance.

Q: How do I check my PA status? A: Log into the Blue Shield member portal, call member services at (800) 535-9481, or have your prescriber check the provider portal.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed prior authorization and appeal letters. Our platform analyzes denial letters, plan policies, and clinical notes to identify the exact denial basis and draft point-by-point rebuttals aligned to each plan's specific requirements. Learn more about how we can help streamline your Tremfya approval process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and requirements change frequently. Always verify current policies with your specific Blue Shield plan and consult your healthcare provider for medical decisions. For personalized assistance with coverage issues, contact the DMHC Help Center at (888) 466-2219 or visit healthhelp.ca.gov.

Getting specialty medications approved can be complex, but Counterforce Health specializes in turning denials into approvals through evidence-based appeals that align with each insurer's specific requirements.

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