By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (guselkumab) Covered by Blue Cross Blue Shield in Washington: Prior Authorization Forms, Appeals, and Coding Guide

Quick Answer: Getting Tremfya Covered by Blue Cross Blue Shield in Washington

Yes, Tremfya (guselkumab) can be covered by Blue Cross Blue Shield plans in Washington, but prior authorization is required. Most plans require step therapy with TNF inhibitors first, tuberculosis screening, and documentation of moderate-to-severe disease. If denied, Washington's strong external review process through Independent Review Organizations (IROs) can overturn decisions. Start today: Have your doctor gather documentation of failed TNF inhibitor trials, obtain TB screening results, and submit the plan-specific prior authorization form through your provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping and Documentation Requirements
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification with Blue Cross Blue Shield Resources
  7. Appeals Process in Washington State
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding how Tremfya is covered depends on where it's administered and billed:

Pharmacy Benefit (Self-Administration)

  • When patients self-administer Tremfya at home
  • Managed under Outpatient Pharmacy Benefit
  • Contact Blue Shield Pharmacy Services for prior authorization
  • Must use in-network specialty pharmacy (CVS Specialty, BioPlus)

Medical Benefit (Provider Administration)

  • When self-administration isn't feasible at home
  • Requires clinical review with documentation explaining why
  • Uses HCPCS code J1628 (billed per 1 mg)
  • Standard covered dose: up to 100 mg subcutaneously
Note: Most Blue Cross Blue Shield plans in Washington prefer the pharmacy benefit pathway for cost management, but medical necessity can justify provider administration.

ICD-10 Mapping and Documentation Requirements

Primary ICD-10 Codes for Tremfya

Condition ICD-10 Code Documentation Requirements
Plaque Psoriasis L40.0 (Psoriasis vulgaris) PASI ≥10 OR BSA ≥3% OR sensitive areas affected
Psoriatic Arthritis L40.50-L40.59 (specific subtypes) Joint involvement, imaging, lab results (CRP/ESR)
Crohn's Disease K50.00-K50.9 Endoscopic findings, failed conventional therapy
Ulcerative Colitis K51.00-K51.90 Mayo score, extent of disease, treatment history

Documentation Words That Support Coding

For Severity Documentation:

  • "Moderate-to-severe" plaque psoriasis
  • "Failed conventional therapy including..."
  • "Contraindicated due to..."
  • "Intolerant to previous TNF inhibitor"
  • "Functional impairment in daily activities"

Clinical Evidence Required:

  • PASI scores for psoriasis patients
  • Joint assessment for psoriatic arthritis
  • Endoscopy reports for IBD
  • Laboratory results (CRP, ESR, fecal calprotectin)
  • Prior treatment documentation with outcomes

Product Coding: HCPCS, J-Codes, and NDC Numbers

Key Coding Information

HCPCS Code: J1628 (billed per 1 mg) Standard Dose: 100 mg subcutaneously Billing Units: 100 units per injection (100 mg = 100 units of J1628) NDC Numbers: Check current Blue Cross Blue Shield formulary for covered NDCs

Dosing Schedule and Units Math

Initial Treatment:

  • Week 0: 100 mg (100 units of J1628)
  • Week 4: 100 mg (100 units of J1628)

Maintenance:

  • Every 8 weeks: 100 mg (100 units of J1628)
Tip: Always verify current NDC numbers with your specific Blue Cross Blue Shield plan, as covered products may vary between Premera Blue Cross, Regence BlueShield, and other Washington Blues plans.

Clean Prior Authorization Request Anatomy

Essential Components of a Strong PA Request

  1. Patient Demographics
    • Full name, DOB, member ID
    • Prescribing physician information
    • Diagnosis with specific ICD-10 codes
  2. Clinical Justification
    • Disease severity scores (PASI, BSA, Mayo score)
    • Previous treatment history with outcomes
    • Reason for TNF inhibitor failure or contraindication
    • TB screening results (within 12 months)
  3. Treatment Plan
    • Exact dosing schedule (100 mg at weeks 0, 4, then q8w)
    • Duration of therapy requested
    • Monitoring plan
  4. Supporting Documentation
    • Recent clinic notes
    • Laboratory results
    • Imaging studies (if applicable)
    • Prior authorization forms from previous medications

Sample Medical Necessity Statement

"Patient has moderate-to-severe plaque psoriasis with PASI score of 12 and BSA involvement of 15%. Failed adequate trial of adalimumab (12 weeks) due to lack of efficacy with <25% improvement in PASI score. TB screening completed with negative QuantiFERON-Gold test on [date]. Tremfya is medically necessary as next-line biologic therapy per AAD guidelines."

Frequent Coding and Billing Pitfalls

Common Errors to Avoid

Unit Conversion Mistakes

  • Billing 1 unit instead of 100 units for J1628
  • Confusing mg with mL (100 mg = 1 mL per injection)
  • Missing modifier codes when required

Documentation Gaps

  • Missing TB screening results
  • Inadequate prior therapy documentation
  • Wrong ICD-10 codes (using unspecified codes like L40.9)
  • Missing severity scores or measurements

Timing Issues

  • Submitting PA after medication start date
  • Missing reauthorization deadlines (typically 12 months)
  • Not allowing adequate processing time (5-10 business days)

Process Errors

  • Using wrong Blue Cross Blue Shield plan's forms
  • Submitting to incorrect department (medical vs. pharmacy)
  • Missing required attestations or signatures

Verification with Blue Cross Blue Shield Resources

How to Cross-Check Codes and Requirements

  1. Access Provider Portal
    • Log into your specific plan's provider portal
    • Verify current formulary status for Tremfya
    • Download most recent prior authorization forms
  2. Confirm Coding Requirements
    • Check medical policy for covered NDCs
    • Verify J1628 units and billing requirements
    • Confirm any modifier requirements
  3. Review Step Therapy Requirements
    • Identify required first-line agents
    • Document contraindications or failures
    • Confirm exception criteria

Key Resources by Plan

Premera Blue Cross: Provider portal and medical policies section Regence BlueShield: Provider resources and drug formulary tools General Blues Plans: Contact provider services for plan-specific requirements

Important: Requirements can vary significantly between different Blue Cross Blue Shield plans in Washington. Always verify with your specific plan.

Appeals Process in Washington State

Washington offers robust protection for patients facing medication denials through a structured appeals process.

Internal Appeals (Required First Step)

Timeline: Submit within 60 days of denial notice Process:

  1. Complete plan's internal appeal form
  2. Include all supporting clinical documentation
  3. Request expedited review if medically urgent
  4. Receive decision within 30 days (72 hours for expedited)

External Review Through Independent Review Organizations (IROs)

When to Use: After exhausting internal appeals Timeline: File within 4 months of final internal denial Process:

  1. Submit external review request to Washington Office of Insurance Commissioner (OIC)
  2. OIC assigns certified IRO using rotational system
  3. Submit additional medical evidence within 5 business days
  4. IRO decision within 20-45 days (72 hours for expedited)
  5. Decision is binding on insurer

Contact Information:

  • Washington State Office of Insurance Commissioner
  • Consumer Advocacy: 1-800-562-6900
  • Website: insurance.wa.gov

Success Strategies for Appeals

Document Medical Necessity Clearly

  • Reference FDA labeling and clinical guidelines
  • Include peer-reviewed literature supporting off-label use
  • Provide detailed treatment history with outcomes

Use Washington-Specific Rights

  • Cite RCW 48.43.535 (external review statute)
  • Reference patient protection laws
  • Include OIC complaint if process violations occur
From our advocates: We've seen Washington patients successfully overturn Tremfya denials by thoroughly documenting TNF inhibitor failures and emphasizing functional impairment. The key is providing specific dates, dosages, and measurable outcomes from previous treatments. IRO reviewers particularly value objective severity scores and quality of life impacts.

Quick Audit Checklist

Pre-Submission Review

Patient Information:

  • Complete demographics and member ID verified
  • Current insurance card information confirmed
  • Correct Blue Cross Blue Shield plan identified

Clinical Documentation:

  • Appropriate ICD-10 code selected (avoid unspecified codes)
  • Disease severity documented with objective measures
  • TB screening completed and documented (within 12 months)
  • Prior therapy trials documented with specific outcomes

Coding Accuracy:

  • Correct HCPCS code (J1628) and units (100 per injection)
  • Current NDC numbers verified with plan formulary
  • Proper billing pathway identified (medical vs. pharmacy benefit)
  • All required modifiers included

Process Compliance:

  • Plan-specific PA form completed fully
  • All supporting documents attached
  • Submission method confirmed (portal, fax, mail)
  • Follow-up plan established for tracking approval

Costs and Patient Support Options

Manufacturer Support Programs

Janssen CarePath for Tremfya

  • Copay assistance for eligible patients
  • Prior authorization support services
  • Patient education materials
  • Website: janssencarepath.com/hcp/tremfya

Washington State Resources

Apple Health (Medicaid) Coverage

  • Different PA criteria may apply
  • Contact managed care plan directly
  • Fair hearing process available for denials

Insurance Commissioner Assistance

  • Free consumer advocacy services
  • Help navigating appeals process
  • Complaint filing for process violations

Frequently Asked Questions

How long does Blue Cross Blue Shield PA take in Washington? Standard prior authorization decisions are typically made within 5-10 business days. Expedited reviews for urgent cases are decided within 72 hours.

What if Tremfya is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing documentation that preferred alternatives are inappropriate or ineffective.

Can I request an expedited appeal if my condition is worsening? Yes, Washington law requires expedited appeals when delays could seriously jeopardize your health. Include specific clinical evidence of deterioration.

Does step therapy apply if I failed TNF inhibitors in another state? Yes, documented treatment failures from other states are typically accepted. Ensure you have complete medical records showing the trial duration and outcomes.

What happens if the IRO denies my external appeal? The IRO decision is final for the insurance appeal process, but you can contact the OIC for additional guidance or consider legal consultation for complex cases.

How much does Tremfya cost without insurance coverage? List prices vary, but Tremfya is a specialty biologic with significant costs. The manufacturer's copay program and patient assistance foundations may help reduce out-of-pocket expenses.

When to Contact Counterforce Health

Navigating insurance approvals for specialty biologics like Tremfya can be complex, especially when dealing with prior authorization requirements and appeals. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

If you're facing repeated denials or need help crafting a compelling appeal, Counterforce Health's system can pull the right medical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet Washington's procedural requirements while tracking deadlines and required documentation.

Sources and 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 Blue Cross Blue Shield plan and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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