By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (guselkumab) Covered by Aetna in Washington: Appeals Guide with State Protections

Answer Box: Getting Tremfya (guselkumab) Covered by Aetna in Washington

Fastest path to approval: Submit Aetna's prior authorization form with specialist documentation of diagnosis severity, prior treatment failures, and medical necessity. If denied, use Washington's internal appeal (180 days) followed by independent review organization (IRO) process for binding decisions.

Start today: Contact your dermatologist or rheumatologist to request a detailed medical necessity letter addressing Aetna's step therapy requirements and your specific clinical situation.

Table of Contents

  1. Why Washington State Rules Matter
  2. Aetna's Tremfya Coverage Requirements
  3. Prior Authorization Timeline Standards
  4. Step Therapy Protections in Washington
  5. Appeals Process: Internal to External Review
  6. Required Documentation for Medical Necessity
  7. When and How to Request External Review
  8. Practical Scripts for Aetna Calls
  9. Understanding Plan Limitations
  10. Quick Reference Resources
  11. FAQ

Why Washington State Rules Matter

Washington's insurance regulations provide crucial protections when seeking Tremfya (guselkumab) coverage through Aetna. The state requires insurers to follow specific timelines for prior authorization decisions and offers robust appeal rights that can override Aetna's initial denials.

How State and Plan Policies Interact

Aetna operates under both its national medical policies and Washington state requirements. While Aetna sets its own coverage criteria for Tremfya, Washington law governs:

  • Decision timelines (urgent vs. non-urgent requests)
  • Appeal procedures and deadlines
  • External review through independent organizations
  • Step therapy exception processes

Line-of-Business Differences

Coverage varies by plan type:

  • Commercial plans: Full Washington protections apply
  • Medicare Advantage: Federal rules take precedence
  • Medicaid (Apple Health): State-specific fair hearing process
  • Self-funded employer plans: Limited state oversight (ERISA governed)

Aetna's Tremfya Coverage Requirements

Tremfya requires prior authorization across most Aetna plans. The Aetna precertification list confirms this requirement for specialty biologics.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must get approval before filling Aetna PA forms
Step Therapy Try other medications first Plan-specific formulary
Specialty Pharmacy Must use designated pharmacy CVS Specialty
Diagnosis Requirements Moderate-to-severe plaque psoriasis or psoriatic arthritis FDA labeling criteria

Prior Authorization Timeline Standards

Washington requires Aetna to meet specific decision timelines:

Standard Requests

  • Non-urgent: 14-30 days maximum
  • Documentation: Submit complete PA form with clinical notes

Expedited Requests

  • Urgent/life-threatening: 72 hours maximum
  • Criteria: Delay could seriously jeopardize health
Tip: Mark requests as urgent when switching from a failing biologic or when disease is rapidly progressing.

Step Therapy Protections in Washington

While Washington doesn't have a specific "safe step" law for biologics, the state requires insurers to provide medical exception processes for step therapy requirements.

Medical Exception Criteria

Aetna must grant step therapy overrides when you document:

  1. Prior failure: Tried required medications with inadequate response
  2. Contraindication: Medical reason why step therapy drugs are inappropriate
  3. Adverse reaction: Previous serious side effects to required medications
  4. Stability: Currently stable on requested therapy

Documentation That Helps

Include these key phrases in your medical necessity letter:

  • "Patient has documented failure of [specific TNF inhibitor] due to [lack of efficacy/adverse effects]"
  • "Contraindicated due to [specific medical condition/risk factor]"
  • "Delay in treatment may result in irreversible joint damage/disease progression"

Appeals Process: Internal to External Review

Washington provides a two-tier appeal system that can override Aetna's coverage decisions.

Step 1: Internal Appeals

Timeline: Must file within 180 days of denial Decision time:

  • Standard: 30-45 days
  • Expedited: 72 hours

How to file: Use Aetna's appeal form or submit written request to address on denial letter.

Step 2: External Review (IRO)

When eligible: After final internal denial Timeline: 180 days to request external review Decision: Binding on Aetna if overturned

Process: Submit request through Washington Office of Insurance Commissioner or directly to Aetna.

Note: The IRO decision is final and binding. If they overturn Aetna's denial, Aetna must cover Tremfya as directed.

Required Documentation for Medical Necessity

Clinician Corner: Medical Necessity Letter Checklist

Your specialist should address these elements:

✓ Diagnosis: Confirmed moderate-to-severe plaque psoriasis or psoriatic arthritis with ICD-10 codes ✓ Disease severity: Body surface area affected, PASI score, or joint involvement ✓ Prior treatments: Specific medications tried, doses, duration, and outcomes ✓ Treatment failures: Why conventional therapy (methotrexate, phototherapy) was inadequate ✓ Biologic history: Any prior TNF inhibitors or other biologics with failure reasons ✓ Clinical rationale: Why Tremfya is medically necessary now ✓ Dosing plan: FDA-approved dosing (100mg at weeks 0, 4, then every 8 weeks) ✓ Monitoring plan: Follow-up schedule and safety monitoring

Supporting Documentation

Attach these records:

  • Recent dermatology/rheumatology notes (last 6 months)
  • Laboratory results (CBC, liver function, TB screening)
  • Imaging studies showing joint damage (if psoriatic arthritis)
  • Previous treatment records showing failures

When and How to Request External Review

Triggers for External Review

Request external review when Aetna denies based on:

  • "Not medically necessary"
  • "Experimental/investigational"
  • Step therapy not satisfied
  • Non-formulary status

Filing Process

  1. Contact method: Call Washington OIC at 1-800-562-6900 or submit online
  2. Required information:
    • Aetna denial letter
    • All internal appeal documentation
    • Additional medical records
  3. Timeline: IRO has 30 days for standard review, 72 hours for expedited

The Washington OIC appeals page provides templates and guidance.

Practical Scripts for Aetna Calls

Patient Script for Aetna Customer Service

"I'm calling about prior authorization for Tremfya for my psoriasis. My doctor submitted the PA form, and I want to check the status. My member ID is [ID number]. Can you tell me what additional information you need and the expected decision timeline?"

Clinic Staff Script for Peer-to-Peer

"I'm requesting a peer-to-peer review for [patient name]'s Tremfya prior authorization. The patient has moderate-to-severe psoriasis with documented failure of [prior treatments]. When can our dermatologist speak with your medical director?"

Understanding Plan Limitations

ERISA Plan Differences

If you have employer-sponsored insurance through a self-funded plan:

  • Washington state appeals may not apply
  • Follow plan's Summary Plan Description (SPD) procedures
  • Contact U.S. Department of Labor for ERISA plan disputes

Coverage Exclusions

Aetna may not cover Tremfya for:

  • Off-label uses not supported by clinical evidence
  • Cosmetic indications
  • Conditions where other treatments haven't been tried
From our advocates: "We've seen many Tremfya denials overturned in Washington when patients provide comprehensive documentation of prior treatment failures. The key is showing you've tried conventional therapy and explaining why Tremfya is specifically needed for your situation. Don't give up after the first denial—Washington's external review process has helped many patients access this medication."

Quick Reference Resources

Washington State Contacts

  • Insurance Commissioner: 1-800-562-6900
  • Appeals guidance: insurance.wa.gov/appeals
  • Consumer assistance: File complaints online at OIC website

Aetna Contacts

  • Member services: Number on back of insurance card
  • Prior authorization: Aetna PA portal
  • Appeals: Submit to address on denial letter

Patient Support Programs

  • Janssen CarePath: Tremfya manufacturer support program
  • CVS Specialty: Aetna's preferred specialty pharmacy
  • Washington prescription assistance: Contact OIC for state programs

FAQ

How long does Aetna prior authorization take for Tremfya in Washington? Standard requests: 14-30 days. Urgent requests: 72 hours maximum per Washington state requirements.

What if Tremfya is not on Aetna's formulary? Request a formulary exception with medical necessity documentation. Washington requires insurers to have an exception process for non-formulary medications.

Can I request an expedited appeal if Aetna denies Tremfya? Yes, if delay could seriously jeopardize your health. Mark appeals as urgent and provide clinical justification for expedited review.

Does step therapy apply if I tried biologics under a different insurance plan? Yes, prior treatment history from other plans counts. Provide documentation of previous biologic failures to support step therapy exceptions.

What happens if the Washington IRO overturns Aetna's denial? The decision is binding on Aetna. They must provide coverage for Tremfya as directed by the IRO decision.

How much does Tremfya cost if Aetna doesn't cover it? Tremfya is a specialty biologic with high costs. Contact Janssen CarePath for manufacturer assistance programs and explore other coverage options.

At Counterforce Health, we help patients navigate complex prior authorization and appeals processes for specialty medications like Tremfya. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address payer-specific requirements. We understand that getting coverage for biologics can be overwhelming, which is why we focus on turning insurance denials into successful approvals through systematic, data-driven approaches.

If you're facing a Tremfya denial from Aetna in Washington, remember that the state's consumer protections provide multiple avenues for appeal. The combination of internal appeals, external review through independent organizations, and proactive support from the Office of Insurance Commissioner gives Washington residents strong tools to fight coverage denials. Don't hesitate to use these resources—many patients have successfully overturned initial denials and gained access to needed specialty medications through Washington's robust appeals process.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage questions. For additional help with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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