By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Blue Cross Blue Shield in Ohio: Complete 2024 Guide with Forms and Appeals

Answer Box: Getting Tremfya Covered in Ohio

Blue Cross Blue Shield Ohio requires prior authorization for Tremfya (guselkumab) with step therapy requirements. You'll need PASI score ≥10, documented failure of preferred biologics like Humira, and TB screening within 12 months. Submit through CVS Caremark Specialty at (866) 752-7021. If denied, you have 180 days for internal appeal, then external review through Ohio Department of Insurance within 120 days at no cost. First step today: Call your specialist to start prior authorization and verify your plan's current formulary status.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy
  4. Specialty Pharmacy Requirements
  5. Cost-Share Dynamics
  6. Submission Process
  7. Common Approval Patterns
  8. Appeals Process for Ohio
  9. Cost Assistance Programs
  10. FAQ

Plan Types & Coverage Implications

Blue Cross Blue Shield Ohio operates several plan types, each with different Tremfya coverage rules:

Commercial Plans (HMO/PPO/POS)

  • Tremfya listed as specialty tier with prior authorization required
  • PPO plans may offer out-of-network coverage at higher cost-share
  • HMO plans require specialist referrals from primary care physician

Medicare Advantage Plans

  • Coverage varies significantly; some plans show Tremfya as not covered
  • Step therapy requirements typically more stringent than commercial plans
  • May require medical exception process if not on formulary

Medicaid Managed Care

  • Prior authorization required through Ohio Department of Medicaid
  • Different submission process than commercial plans
  • May have additional state-specific requirements
Note: Self-funded employer plans follow federal ERISA law but often use similar processes to fully-insured plans.

Formulary Status & Tier Placement

Tremfya is classified as a specialty medication across Blue Cross Blue Shield Ohio formularies. Here's what this means:

Plan Type Formulary Status Tier Placement PA Required
Commercial HMO/PPO Non-preferred specialty Tier 4-5 Yes
Medicare Advantage Variable/Not covered N/A Yes
Exchange Plans Non-preferred Specialty tier Yes

Alternative agents that may be preferred include:

  • Humira (adalimumab) - TNF inhibitor
  • Skyrizi (risankizumab) - IL-23 inhibitor
  • Stelara (ustekinumab) - IL-12/23 inhibitor
  • Cosentyx (secukinumab) - IL-17 inhibitor

Prior Authorization & Step Therapy

Clinical Documentation Requirements

Disease Severity Documentation

  • PASI score ≥10 or body surface area (BSA) ≥10% for plaque psoriasis
  • Active psoriatic arthritis with inadequate response to conventional DMARDs
  • Clinical notes supporting moderate-to-severe disease

Step Therapy Requirements You must document trial and failure of:

  1. Topical therapies (for psoriasis)
  2. Conventional systemic agents (methotrexate, cyclosporine)
  3. Preferred biologic therapy (typically TNF inhibitor like Humira)

TB Screening

  • QuantiFERON-TB Gold test (preferred) or tuberculin skin test
  • Results must be within 12 months of PA request
  • Chest X-ray may also be required

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must be approved before dispensing CVS Caremark Specialty ✓
Step Therapy Try preferred drugs first Plan formulary ✓
Specialty Pharmacy Must use designated network Anthem provider portal ✓
PASI Score ≥10 Disease severity requirement Clinical documentation ✓
TB Screening Safety requirement Lab results ✓

Specialty Pharmacy Requirements

Tremfya must be dispensed through Blue Cross Blue Shield Ohio's designated specialty pharmacy network:

Approved Specialty Pharmacies:

  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
  • CVS Specialty
Critical: Using an out-of-network pharmacy may result in no coverage, leaving you responsible for the full cost (potentially $15,000+ per dose).

Patient Setup Process:

  1. Physician submits PA to CVS Caremark Specialty
  2. Specialty pharmacy contacts patient for enrollment
  3. Patient completes intake call and insurance verification
  4. Pharmacy coordinates delivery and injection training if needed

Cost-Share Dynamics

Understanding your out-of-pocket costs helps with financial planning:

Specialty Tier Cost-Sharing (Educational)

  • Commercial plans: Typically 25-40% coinsurance after deductible
  • Medicare Advantage: Varies widely, some plans $0-$47 per month in coverage gap
  • Exchange plans: Subject to annual out-of-pocket maximum

Deductible Application Most plans apply specialty medications to the medical or pharmacy deductible before coinsurance kicks in.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Verify Current Coverage (Patient)
    • Call member services number on insurance card
    • Confirm Tremfya is on current formulary
    • Timeline: 15 minutes
  2. Gather Clinical Documentation (Clinic)
    • PASI scores or BSA measurements
    • Prior therapy records with outcomes
    • TB screening results
    • Timeline: 1-2 business days
  3. Submit Prior Authorization (Physician)
    • Complete PA form with clinical rationale
    • Fax to CVS Caremark: (888) 267-7277
    • Timeline: 72 hours for standard review
  4. Specialty Pharmacy Enrollment (Patient)
    • Accept call from designated specialty pharmacy
    • Complete intake and insurance verification
    • Timeline: 3-5 business days
  5. Track Authorization Status (Patient/Clinic)
    • Call CVS Caremark: (866) 752-7021
    • Follow up if no response within 5 business days
    • Timeline: Ongoing

Common Approval Patterns

Strong submissions typically include:

Clinical Narrative Elements:

  • Clear diagnosis with ICD-10 codes (L40.0 for plaque psoriasis, L40.5 for psoriatic arthritis)
  • Quantified disease severity (PASI score, affected BSA percentage)
  • Detailed prior therapy history with specific outcomes
  • Clinical rationale citing FDA labeling or specialty guidelines

Documentation Best Practices:

  • Include photographs of affected areas (with patient consent)
  • Laboratory results supporting safety monitoring
  • Patient-reported outcome measures (DLQI, HAQ-DI)
From our advocates: We've seen approvals happen faster when physicians include a brief paragraph explaining why Tremfya specifically is the most appropriate choice compared to alternatives, rather than just stating that other drugs failed. This clinical context helps reviewers understand the medical necessity.

Appeals Process for Ohio

Internal Appeal (Level 1)

Timeline: 180 days from denial date Process: Submit written appeal to address on denial letter Review Time: 30 days standard, 72 hours if expedited

Required Documentation:

  • Copy of original denial letter
  • Additional clinical evidence
  • Physician letter supporting medical necessity
  • Patient impact statement (optional but helpful)

External Review (Level 2)

Timeline: 120 days from final internal denial Cost: Free to patient (insurer pays) Authority: Ohio Department of Insurance

How to Request:

  1. Call ODI Consumer Services: 1-800-686-1526
  2. Complete External Review Request Form
  3. Submit to your health plan (they forward to ODI)

Review Process:

  • Independent Review Organization (IRO) assigned
  • Panel of 3+ physicians with relevant clinical experience
  • 30 days for standard review, 72 hours if expedited
  • Decision is binding on insurer

When to Escalate

Contact Ohio Department of Insurance if:

  • Insurer claims your case isn't eligible for external review
  • Appeals deadlines are being missed
  • You're experiencing procedural barriers

For patients navigating complex insurance denials, Counterforce Health helps turn denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to identify the specific basis for denial and draft point-by-point rebuttals aligned to the plan's own rules.

Cost Assistance Programs

Manufacturer Support:

  • Janssen CarePath: Copay assistance as low as $5 per dose for commercially insured patients
  • Patient support services and injection training

Foundation Grants:

State Programs:

  • Ohio Department of Health pharmaceutical assistance programs
  • Local health department resources

FAQ

How long does Blue Cross Blue Shield PA take in Ohio? Standard prior authorization takes 72 hours to 5 business days. Expedited reviews for urgent cases take 24-72 hours.

What if Tremfya is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and why preferred alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if delay would seriously endanger your health or prevent you from regaining maximum function. Your physician must certify the urgency.

Does step therapy apply if I failed biologics in another state? Medical records from other states are generally accepted, but you may need to provide detailed documentation of prior therapy outcomes.

What happens if my appeal is denied? After exhausting internal appeals, you can request external review through Ohio Department of Insurance. The IRO decision is binding on your insurer.

How do I verify my specialty pharmacy options? Call the member services number on your insurance card or check your plan's provider directory online.

Can my doctor do a peer-to-peer review? Yes, physicians can request to speak directly with the plan's medical director. This is often helpful for complex cases.

What if I'm switching from another biologic? You may still need to meet step therapy requirements unless you have documented contraindications or intolerances to preferred agents.

For complex coverage challenges, Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted appeals that address the specific denial basis with evidence-backed rebuttals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently. Always verify current requirements with your specific Blue Cross Blue Shield Ohio plan and consult with your healthcare provider about treatment decisions. For assistance with insurance appeals, contact the Ohio Department of Insurance or consider working with a patient advocacy service.

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