By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Aetna CVS Health in California: Prior Authorization, Appeals & Cost Savings

Answer Box: Fast Track to Tremfya Coverage

Getting Tremfya (guselkumab) covered by Aetna CVS Health in California requires prior authorization through a dermatologist or rheumatologist. Submit documentation showing moderate-to-severe disease (≥10% body surface area or crucial areas affected) plus failure/intolerance of conventional treatments. First step: Have your specialist complete Aetna's CA prescription drug prior authorization form with clinical notes, lab results, and prior treatment history. Submit via fax (888-267-3277) or online portal. Standard decisions take 24-48 hours. If denied, California's Independent Medical Review process has a 73% success rate for specialty drug appeals.

Table of Contents

  1. Understanding Tremfya Coverage Requirements
  2. Step-by-Step Prior Authorization Process
  3. Cost-Saving Strategies and Assistance Programs
  4. When Your Request Gets Denied: Appeals Process
  5. California's Independent Medical Review (IMR)
  6. Specialty Pharmacy Requirements
  7. Common Denial Reasons & How to Fix Them
  8. Patient Scripts and Templates
  9. FAQ: Most Asked Questions

Understanding Tremfya Coverage Requirements

Tremfya (guselkumab) is an IL-23 p19 inhibitor used to treat moderate-to-severe plaque psoriasis, psoriatic arthritis, and inflammatory bowel diseases. Aetna CVS Health requires prior authorization for all Tremfya prescriptions in California, with specific clinical criteria that must be met.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before filling Aetna's 2024 precertification list Aetna PA Requirements
Specialist Required Dermatologist or rheumatologist Clinical policy bulletin Aetna Clinical Policy
Step Therapy Prior treatment attempts required Plan formulary guidelines Aetna Formulary
Specialty Pharmacy Only Must use CVS Specialty or approved network Specialty drug list CVS Specialty Requirements
Quantity Limits Apply Dosing restrictions may apply Post-limit exception criteria Aetna Quantity Limits

Key Clinical Criteria

For plaque psoriasis, you must meet one of these conditions:

  • Previous biologic or targeted synthetic drug use, OR
  • Moderate-to-severe disease defined by:
    • Involvement of crucial areas (hands, face, scalp, genitals)
    • At least 10% body surface area affected
    • At least 3% BSA with documented failure/intolerance of phototherapy or systemic drugs (methotrexate, cyclosporine, acitretin)

For psoriatic arthritis, similar requirements apply with rheumatologist involvement or consultation required.

Note: Unlike some other states, California regulations limit insurers' ability to require failure of every preferred agent. Aetna cannot mandate TNF inhibitor failure if there's documented clinical justification for Tremfya.

Step-by-Step Prior Authorization Process

Step 1: Gather Required Documentation

Who does it: Your clinic staff
Timeline: 1-2 days before submission

Collect:

  • Complete medical history with ICD-10 codes
  • PASI scores or body surface area measurements
  • Documentation of prior treatments and outcomes
  • Lab results (including TB screening)
  • Current clinical notes from specialist

Step 2: Complete PA Form

Who does it: Prescribing physician
Document needed: California-specific PA form

Include:

  • Patient demographics and insurance information
  • Diagnosis with ICD-10 codes
  • Detailed clinical rationale
  • Prior therapy history with specific dates and outcomes
  • Prescriber attestation and signature

Step 3: Submit to Aetna

Submission options:

  • Fax: 888-267-3277 (most reliable)
  • Online: Availity provider portal
  • Phone: 855-240-0535 (Mon-Fri, 8 AM-6 PM CT)

Expected timeline: 24-48 hours for standard decisions

Step 4: Coordinate with Specialty Pharmacy

Who does it: Patient or clinic
Timeline: After PA approval

Contact CVS Specialty (800-237-2767) to:

  • Verify insurance benefits
  • Arrange delivery and injection training
  • Set up adherence monitoring

Cost-Saving Strategies and Assistance Programs

Manufacturer Copay Assistance

The Janssen CarePath Savings Card can significantly reduce out-of-pocket costs for eligible patients with commercial insurance.

Eligibility requirements:

  • Age 18 or older
  • Commercial or private insurance (including ACA marketplace plans)
  • NOT eligible: Medicare, Medicaid, TRICARE, VA benefits
  • NOT eligible: Plans with "maximizer" or "optimizer" programs

How to enroll:

Tip: If your pharmacy can't process the savings card, submit a rebate form online with your receipt and explanation of benefits.

Foundation Assistance Programs

For patients who don't qualify for manufacturer assistance:

  • Patient Access Network Foundation
  • Good Days (formerly Chronic Disease Fund)
  • HealthWell Foundation

Income limits and eligibility vary by program. Most require proof of financial need and denial of manufacturer assistance.

Formulary Tier Optimization

If Tremfya is on a high-cost tier, request a formulary exception to move it to a lower tier. This requires:

  • Medical necessity letter from prescriber
  • Documentation that preferred alternatives are ineffective or inappropriate
  • Clinical evidence supporting Tremfya's superiority for your specific case

When Your Request Gets Denied: Appeals Process

Internal Appeals with Aetna

Timeline: Must file within 60 days of denial notice

Standard appeal: 30 days for decision
Expedited appeal: 72 hours for urgent medical needs

Required documents:

  • Copy of original denial letter
  • Additional medical records or clinical studies
  • Updated letter of medical necessity
  • Any new relevant clinical information

Submission methods:

  • Mail: Aetna Appeals, PO Box 14079, Lexington, KY 40512-4079
  • Fax: 859-425-3379
  • Online: Through member or provider portal

Peer-to-Peer Review

Request a peer-to-peer review where your prescribing physician speaks directly with Aetna's medical director. This often resolves denials based on clinical misunderstandings.

To request: Call Aetna provider services and ask for peer-to-peer scheduling.

California's Independent Medical Review (IMR)

California offers one of the strongest external review processes in the nation through the Department of Managed Health Care (DMHC).

IMR Success Rates

Specialty drug appeals have a 73% overturn rate with California's IMR process—significantly higher than the overall 12-13% overturn rate for all services. This makes IMR particularly valuable for Tremfya denials.

How to Request IMR

Eligibility: Must exhaust Aetna's internal appeals first

Timeline: File within 180 days of final internal denial

Process:

  1. Complete IMR application online or by phone
  2. Submit all medical records and denial letters
  3. DMHC assigns case to independent medical experts
  4. Decision typically within 30-45 days (expedited: 72 hours for urgent cases)

Cost: Free to patients—insurers pay all review costs

From our advocates: "We've seen multiple Tremfya denials overturned through California's IMR process when patients provided comprehensive documentation of prior treatment failures and specialist letters clearly explaining why conventional therapies weren't appropriate. The key is thorough documentation of the medical necessity."

DMHC Contact Information

Help Center: 888-466-2219
Website: healthhelp.ca.gov
Online IMR application: Available in multiple languages

Specialty Pharmacy Requirements

Tremfya must be dispensed through an approved specialty pharmacy for Aetna coverage. Retail pharmacies cannot dispense this medication under most Aetna plans.

Approved Specialty Pharmacies

  • CVS Specialty: 800-237-2767 (primary option)
  • Other Aetna-contracted specialty pharmacies (verify network status)

What Specialty Pharmacies Provide

  • Insurance verification and prior authorization coordination
  • Patient education and injection training
  • Adherence monitoring and refill reminders
  • Clinical support and side effect management
  • Direct delivery to home or clinic

Important: Attempting to fill Tremfya at a retail pharmacy will result in claim denial and full out-of-pocket cost responsibility.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide detailed clinical history PASI scores, photos, quality of life assessments
"Step therapy not completed" Document prior failures/intolerances Pharmacy records, physician notes, adverse event reports
"Missing TB screening" Complete required testing QuantiFERON Gold or TST results, chest X-ray
"Non-formulary drug" Request formulary exception Comparative effectiveness literature, cost analysis
"Quantity limit exceeded" Submit exception request Dosing rationale, clinical guidelines supporting frequency
"Experimental/investigational" Provide FDA approval evidence FDA prescribing information, published clinical trials

Patient Scripts and Templates

Script for Calling Aetna

"Hello, I'm calling about a prior authorization denial for Tremfya, prescription number [X]. My member ID is [X]. I'd like to understand the specific reason for denial and what additional information is needed for approval. Can you also tell me about the appeals process and timeline?"

Key questions to ask:

  • What specific clinical criteria weren't met?
  • Can you provide the exact policy citation?
  • Is peer-to-peer review available?
  • What's the deadline for filing an appeal?

Template for Medical Necessity Letter

Counterforce Health helps patients and clinicians create compelling, evidence-based appeals that turn insurance denials into approvals. Our platform analyzes denial letters and drafts targeted rebuttals using the payer's own criteria and the latest clinical evidence.

Key elements to include:

  • Patient's complete diagnosis with ICD-10 codes
  • Detailed history of prior treatments and outcomes
  • Clinical rationale for Tremfya specifically
  • Relevant guidelines or literature citations
  • Monitoring plan and treatment goals

FAQ: Most Asked Questions

How long does Aetna prior authorization take in California? Standard decisions are typically made within 24-48 hours of receiving complete documentation. Expedited reviews for urgent cases are decided within 24 hours.

What if Tremfya is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. If denied, California's IMR process has a 73% success rate for specialty drug appeals.

Can I request an expedited appeal? Yes, if delay in treatment would seriously jeopardize your health. Expedited appeals are decided within 72 hours.

Does step therapy apply if I've tried treatments outside California? Yes, prior treatment history from other states counts toward step therapy requirements. Provide complete pharmacy records and physician notes.

What happens if I lose Aetna coverage during treatment? Contact your new insurer immediately to start the prior authorization process. Janssen offers bridge programs to prevent treatment interruptions during insurance transitions.

Can my dermatologist handle the entire approval process? Yes, experienced dermatology practices often manage the entire PA process, from form submission to appeals. Ask your clinic about their prior authorization support services.

How much does Tremfya cost without insurance? List prices exceed $20,000 annually. The Janssen CarePath program can reduce costs significantly for eligible patients with commercial insurance.

What if Aetna requires a different biologic first? Document why preferred alternatives are inappropriate through medical contraindications, prior failures, or clinical factors. Counterforce Health's platform helps create evidence-based arguments for specific drug selection.

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 insurer and consult healthcare professionals for medical decisions. For assistance with complex appeals, contact the California Department of Managed Health Care at 888-466-2219 or visit healthhelp.ca.gov.

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