By Counterforce Health Team in Tremfya (guselkumab) —

Get Tremfya (Guselkumab) Covered by Blue Cross Blue Shield in New Jersey: Complete 2025 Guide

Answer Box: Getting Tremfya Covered in New Jersey

Yes, Tremfya (guselkumab) can be covered by Blue Cross Blue Shield in New Jersey, but it requires prior authorization and typically involves step therapy with TNF inhibitors first. Here's your fastest path to approval:

  1. Complete TB screening and gather documentation of failed TNF inhibitor therapy (or contraindications)
  2. Have your dermatologist submit the prior authorization with PASI score ≥10 or BSA ≥10% documentation
  3. If denied, file an internal appeal immediately, then use New Jersey's IHCAP external review program through Maximus Federal Services

Start today by calling Horizon Blue Cross Blue Shield member services at the number on your insurance card to confirm your specific plan's requirements and obtain the current prior authorization form.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Costs and Coverage Tiers
  6. Denials and Appeals
  7. Renewals and Re-authorization
  8. Specialty Pharmacy Requirements
  9. New Jersey External Appeals (IHCAP)
  10. Common Questions

Coverage Basics

Is Tremfya Covered by Blue Cross Blue Shield in New Jersey?

Tremfya (guselkumab) is covered by most Horizon Blue Cross Blue Shield of New Jersey plans, but it's classified as a specialty medication requiring prior authorization. The drug is typically placed in the specialty tier of formularies, meaning higher out-of-pocket costs but coverage is available when medical necessity criteria are met.

Which Plans Cover Tremfya?

  • Commercial/employer plans: Coverage varies by specific plan design
  • Marketplace (ACA) plans: Generally covered with prior authorization
  • Medicare Advantage: Subject to Medicare Part D rules and plan formulary
  • Medicaid/NJ FamilyCare: Coverage through managed care plans
Note: Each Blue Cross Blue Shield plan maintains its own formulary, so verify coverage with your specific plan before starting treatment.

Prior Authorization Process

Who Submits the Prior Authorization?

Your prescribing physician (typically a dermatologist or rheumatologist) must submit the prior authorization request. Patients cannot submit PA requests directly to Horizon BCBS.

Step-by-Step Submission Process

  1. Obtain the correct PA form from Horizon BCBS provider portal
  2. Gather required documentation (see Medical Necessity Criteria below)
  3. Submit via required channel - typically fax or online provider portal
  4. Track the request through the provider portal or by phone
  5. Respond promptly to any requests for additional information
  6. Receive determination within standard timeframes

Required Documentation Checklist

  • Completed prior authorization form
  • Patient demographics and insurance information
  • Specific FDA-approved diagnosis (plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis)
  • Disease severity documentation (PASI score, BSA involvement, or IGA score)
  • Complete prior therapy history with outcomes
  • TB screening results (negative within 12 months)
  • Prescriber specialty credentials

Timing and Deadlines

Standard Review Timeline

  • Standard prior authorization: 7-14 business days
  • Expedited review (urgent medical need): 72 hours
  • Peer-to-peer review: Additional 2-3 business days if requested

When to Submit

Submit the PA request before the patient's first dose. Claims submitted without prior approval will be denied and may delay treatment initiation.

Tip: Allow extra time during busy periods (January formulary changes, end of year) when PA volumes are higher.

Medical Necessity Criteria

Disease Severity Requirements

Horizon BCBS requires objective documentation of moderate-to-severe disease using at least one of these measures:

Condition Severity Criteria
Plaque Psoriasis PASI ≥10 OR BSA ≥10% OR IGA ≥3
Psoriatic Arthritis Active joint involvement with inadequate response to DMARDs
IBD (Crohn's/UC) Moderate-to-severe disease with prior biologic failure

Step Therapy Requirements

Most Horizon BCBS plans enforce step therapy, requiring documented trial and failure (or contraindication) of:

  • TNF inhibitors (adalimumab, etanercept, infliximab, certolizumab, golimumab)
  • Conventional therapies may also be required (topicals, phototherapy, methotrexate)

TB Screening Mandate

All patients must have negative TB screening documented before Tremfya initiation. Acceptable tests include:

  • QuantiFERON-Gold or similar interferon-gamma release assay
  • Tuberculin skin test (PPD)
  • Chest X-ray

Costs and Coverage Tiers

Specialty Tier Placement

Tremfya is typically placed in the specialty tier, which means:

  • Coinsurance rather than flat copay (usually 25-30% of drug cost)
  • Annual deductible may apply
  • Out-of-pocket maximum protection still applies

Cost-Saving Options

  • Janssen CarePath: Patient assistance program offering copay cards and financial support
  • Foundation grants: Organizations like the Patient Advocate Foundation offer grants for specialty medications
  • State pharmaceutical assistance: New Jersey PAAD program for seniors
From our advocates: We've seen patients reduce their Tremfya costs from over $1,000 per month to under $50 by combining manufacturer copay assistance with their insurance coverage. The key is applying for patient assistance programs before your first fill, as some have income requirements and waiting periods.

Denials and Appeals

Common Denial Reasons

Denial Reason How to Address
Missing TB screening Submit negative TB test results
Insufficient disease severity Provide PASI ≥10, BSA ≥10%, or IGA ≥3 documentation
No step therapy documentation Document TNF inhibitor failure with specific outcomes
Prescriber not specialist Have dermatologist or rheumatologist submit request
Combination therapy Discontinue other biologics before requesting approval

Internal Appeal Process

  1. File within plan deadlines (typically 180 days from denial)
  2. Submit additional clinical documentation addressing denial reasons
  3. Request peer-to-peer review if initial appeal denied
  4. Track appeal status through provider portal

Peer-to-Peer Review Strategy

When requesting a peer-to-peer review:

  • Prepare specific clinical rationale for Tremfya vs. alternatives
  • Have patient's complete treatment history readily available
  • Reference relevant clinical guidelines and FDA labeling
  • Be ready to discuss disease severity and treatment goals

Renewals and Re-authorization

When to Re-authorize

Most Tremfya approvals are granted for 12 months, requiring annual re-authorization. Submit renewal requests 30-60 days before expiration to avoid treatment interruption.

Renewal Documentation

  • Updated disease assessment showing continued need
  • Documentation of treatment response or disease stability
  • Confirmation of ongoing monitoring (labs, infection screening)
  • Any changes in clinical status or concurrent medications

Specialty Pharmacy Requirements

Mandatory Specialty Pharmacy

Horizon BCBS requires Tremfya to be dispensed through in-network specialty pharmacies such as:

  • Accredo Specialty Pharmacy
  • CVS Specialty
  • AllianceRx Walgreens Prime

Specialty Pharmacy Process

  1. Prescription transferred automatically after PA approval
  2. Patient contacted by specialty pharmacy for coordination
  3. Insurance verification and copay assistance enrollment
  4. Delivery scheduled (typically monthly or every 8 weeks)
  5. Ongoing support for injection training and adherence

New Jersey External Appeals (IHCAP)

If your internal appeals are denied, New Jersey offers one of the strongest external review programs in the country through the Independent Health Care Appeals Program (IHCAP).

IHCAP Process Overview

Eligibility: You can file an external appeal if:

  • You've completed Horizon BCBS's internal appeal process
  • The denial relates to medical necessity or experimental/investigational determination
  • You have a New Jersey state-regulated insurance plan

Timeline: File within 4 months of receiving the final internal appeal denial.

How to File with Maximus Federal Services

New Jersey contracts with Maximus Federal Services to manage external appeals:

  1. Complete the External Appeal Application
  2. Submit $25 filing fee
  3. Include copies of denial letters and supporting medical records
  4. Mail or fax to Maximus (contact info provided after internal appeal completion)

IHCAP Success Factors

  • Comprehensive medical documentation from your prescribing physician
  • Clinical literature supporting Tremfya's medical necessity for your condition
  • Clear explanation of why alternative treatments are inappropriate
  • Objective evidence of disease severity and treatment need
Note: The external review decision is binding on your insurance plan. If approved, Horizon BCBS must provide coverage within 10 business days.

Common Questions

Q: How long does Horizon BCBS prior authorization take in New Jersey? A: Standard reviews take 7-14 business days. Expedited reviews for urgent medical situations are completed within 72 hours.

Q: What if Tremfya is non-formulary on my plan? A: You can request a formulary exception with clinical justification. Your doctor will need to demonstrate medical necessity and why preferred alternatives are inappropriate.

Q: Can I request an expedited appeal? A: Yes, if a delay in treatment would seriously jeopardize your health. Both internal appeals and IHCAP external reviews offer expedited processes.

Q: Does step therapy apply if I failed TNF inhibitors outside New Jersey? A: Yes, documented treatment failures from other states are generally accepted if properly documented in your medical records.

Q: What's the difference between medical benefit and pharmacy benefit coverage? A: Tremfya is typically covered under the pharmacy benefit (specialty tier), but some plans may cover it under medical benefit if administered in a clinical setting.

Q: Can my doctor file the external appeal for me? A: Yes, New Jersey allows providers to file IHCAP external appeals on behalf of patients with written consent.

Counterforce Health: Your Coverage Partner

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Tremfya. Our platform analyzes denial letters, identifies the specific coverage criteria, and drafts evidence-backed appeals that align with your plan's own rules. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes, improving approval rates while reducing administrative burden.

For patients facing Tremfya denials in New Jersey, Counterforce Health can help prepare comprehensive appeals that address Horizon BCBS's specific medical necessity criteria and leverage New Jersey's robust external review system.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific insurance plan and consult with your healthcare provider for medical decisions. For personalized assistance with appeals and coverage issues, contact the New Jersey Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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