By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Aetna CVS Health in Michigan: Appeals Guide with Forms and Timelines

Answer Box: Getting Tremfya Covered by Aetna CVS Health in Michigan

Aetna CVS Health requires prior authorization for Tremfya (guselkumab) in Michigan, typically mandating step therapy with TNF inhibitors first. If denied, you have 60 days for internal appeals, then 127 days for Michigan's free external review through DIFS. The fastest path: gather TNF failure documentation, submit complete PA via Availity portal, and if denied, immediately request peer-to-peer review while filing internal appeal. Start today by calling Aetna at 1-866-235-5660 to verify your specific formulary tier and PA requirements.

Table of Contents

  1. Understanding Your Aetna CVS Health Coverage
  2. Prior Authorization Requirements
  3. Common Denial Reasons and Quick Fixes
  4. Step-by-Step Appeal Process
  5. Michigan External Review Process
  6. Medical Necessity Documentation
  7. Cost-Saving Options
  8. When to Escalate
  9. FAQ

Understanding Your Aetna CVS Health Coverage

Tremfya (guselkumab) is an IL-23 p19 inhibitor approved for moderate-to-severe plaque psoriasis, psoriatic arthritis, and inflammatory bowel diseases including Crohn's disease and ulcerative colitis. Under Aetna CVS Health plans in Michigan, this specialty biologic requires prior authorization and is typically classified as a non-preferred (Tier 3) medication.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Aetna Precertification Lists Aetna Policy
Step Therapy Must fail TNF inhibitors first PA criteria documentation Payer Guidelines
Formulary Tier Non-preferred specialty Member portal or call 1-866-235-5660 Aetna Formulary
Site of Care CVS Specialty Pharmacy Specialty drug requirements CVS Caremark
Appeals Deadline 60 days internal, 127 days external Michigan DIFS guidelines Michigan DIFS

Prior Authorization Requirements

Aetna CVS Health's prior authorization for Tremfya follows specific step therapy protocols. You'll need to document failure or intolerance to TNF-alpha inhibitors (like Humira, Enbrel, or Remicade) before guselkumab approval.

Required Documentation

  • Diagnosis confirmation with appropriate ICD-10 codes (L40.0 for psoriasis, M07.3 for psoriatic arthritis)
  • Disease severity metrics (PASI score ≥10 for psoriasis, BSA >10%)
  • Prior therapy failures with specific details on duration, dosing, and reasons for discontinuation
  • Provider attestation of medical necessity
  • Laboratory results including TB screening

Submission Process

Submit your prior authorization through:

  • Availity portal (preferred method)
  • Fax: 1-866-235-5660
  • Phone: 1-866-235-5660
Tip: Submit requests at least 2 weeks before treatment start date. Aetna processes 95% of complete submissions within 24 hours.

Common Denial Reasons and Quick Fixes

Denial Reason How to Fix Required Documents
Missing step therapy Document TNF inhibitor trials Pharmacy records, provider notes
Insufficient disease severity Submit PASI scores, photos Clinical assessment, DLQI scores
Incomplete TB screening Provide screening results Chest X-ray, QuantiFERON Gold
Non-formulary status Request formulary exception Medical necessity letter
Quantity limits exceeded Justify dosing frequency FDA labeling, clinical guidelines

Step-by-Step Appeal Process

Level 1: Internal Appeal (60 days)

  1. Request appeal within 60 days of denial notice
  2. Gather documentation: denial letter, medical records, provider support letter
  3. Submit via Aetna member portal or fax to appeals department
  4. Timeline: 30-day decision for standard appeals, 72 hours for expedited

Peer-to-Peer Review

Before or during your appeal, request a peer-to-peer discussion between your dermatologist/rheumatologist and an Aetna medical director. This optional step often resolves coverage disputes quickly.

To request: Call the dedicated peer-to-peer line or note the request on your appeal form.

Level 2: Second Internal Appeal

If your first appeal is denied, you have another 60 days to file a second-level internal appeal with additional evidence or expert opinions.

Michigan External Review Process

Michigan offers robust consumer protections through the Department of Insurance and Financial Services (DIFS). After exhausting Aetna's internal appeals, you have 127 days to file for external review.

Filing Your External Review

Contact DIFS:

Timeline and Process

  • Standard review: 60 days maximum
  • Expedited review: 72 hours (requires physician urgency letter)
  • Cost: Free to consumers
  • Decision: Binding on Aetna CVS Health
Note: Expedited external reviews require your treating physician to verify in writing that the normal timeframe could seriously jeopardize your health.

Medical Necessity Documentation

Clinician Corner: Building a Strong Medical Necessity Case

Your healthcare provider's documentation is crucial for approval. The medical necessity letter should include:

Essential Elements:

  • Patient identification and diagnosis with ICD-10 codes
  • Disease severity assessment (PASI scores for psoriasis, joint counts for psoriatic arthritis)
  • Prior treatment history with specific medications, durations, and outcomes
  • Clinical rationale for Tremfya over alternatives
  • Treatment goals and expected outcomes
  • Provider credentials and contact information

Supporting Evidence:

  • FDA labeling supporting the indication
  • Clinical guidelines from dermatology or rheumatology societies
  • Peer-reviewed studies demonstrating efficacy
  • Patient quality of life assessments (DLQI scores)

Sample Documentation Framework

"Patient [Name] presents with moderate-to-severe plaque psoriasis (ICD-10 L40.0) with baseline PASI score of 15.2 and BSA involvement of 18%. Previous therapies including topical corticosteroids (12 weeks), methotrexate (16 weeks at 25mg weekly), and adalimumab (6 months) resulted in inadequate response (<PASI50). Patient experienced significant quality of life impairment (DLQI 18/30) with substantial social and psychological impact. Tremfya is medically necessary as an IL-23 inhibitor with proven efficacy in TNF-inadequate responders."

Cost-Saving Options

Even with insurance coverage, Tremfya can be expensive. Consider these assistance programs:

  • Janssen CarePath: Manufacturer copay assistance program
  • Patient Advocate Foundation: Grants for eligible patients
  • Michigan Medicaid: May provide coverage if you qualify
  • Hospital charity care: Many Michigan hospitals offer financial assistance programs

Contact Counterforce Health for assistance navigating these programs and optimizing your coverage strategy.

When to Escalate

If your appeals are unsuccessful, consider these escalation options:

File a Complaint with Michigan DIFS

Contact the Michigan Department of Insurance and Financial Services if you believe Aetna CVS Health violated state insurance regulations:

Michigan DIFS Consumer Services

  • Phone: 877-999-6442
  • Website: michigan.gov/difs
  • Email: Available through online complaint form

Contact Your State Representatives

Michigan legislators can sometimes intervene in complex insurance disputes, particularly those affecting multiple constituents.

For cases involving significant medical necessity disputes or potential bad faith denials, consult with a healthcare attorney experienced in insurance law.

FAQ

How long does Aetna CVS Health prior authorization take in Michigan? Standard decisions take 30-45 days, but complete submissions are often processed within 24 hours. Expedited reviews for urgent cases are completed within 72 hours.

What if Tremfya is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. Include comprehensive documentation of prior therapy failures.

Can I request an expedited appeal? Yes, if your health would be seriously jeopardized by waiting for a standard appeal timeline. Your physician must provide written attestation of urgency.

Does step therapy apply if I failed TNF inhibitors outside Michigan? Yes, documented failures from any location are typically accepted if properly documented with pharmacy records and provider notes.

What happens if my external review is denied? External review decisions in Michigan are binding. However, you may have options through federal appeals processes or by addressing new clinical circumstances.

How can I track my appeal status? Use the Aetna member portal or call member services. Keep detailed records of all communications and reference numbers.

Are there alternatives if all appeals fail? Consider other IL-23 inhibitors like Skyrizi, clinical trials, patient assistance programs, or working with Counterforce Health to explore additional coverage pathways.

From Our Advocates

We've seen many Michigan patients successfully obtain Tremfya coverage after initial denials by thoroughly documenting TNF inhibitor failures and emphasizing functional impairment. The key is often persistence through Michigan's external review process, which provides an independent medical assessment. This is a composite example based on typical successful cases, not a guarantee of outcomes.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned with your plan's own rules. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes for medications like Tremfya.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by specific plan and can change. Always verify current requirements with your insurance provider and consult healthcare professionals for medical decisions. For personalized assistance with insurance appeals, consider consulting with organizations like Counterforce Health that specialize in coverage advocacy.

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