By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Blue Cross Blue Shield Virginia: Prior Authorization Forms, Appeals, and Step-by-Step Guide

Answer Box: Getting Tremfya (Guselkumab) Covered by Blue Cross Blue Shield Virginia

Tremfya (guselkumab) requires prior authorization from Blue Cross Blue Shield Virginia (Anthem). The fastest path to approval involves three steps: 1) Submit complete prior authorization documentation including PASI scores and failed therapy history through Anthem's Availity portal, 2) Use an in-network specialty pharmacy like CVS Specialty or BioPlus, and 3) If denied, file an internal appeal within 60 days, then external review with Virginia's State Corporation Commission within 120 days using Form 216-A.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Must get approval before dispensing Anthem provider portal Anthem PA Updates
Specialty Pharmacy Only Must use designated network pharmacy CVS Specialty, BioPlus, others BCBS Specialty Network
Step Therapy May Apply Try preferred agents first Plan formulary Anthem PA Requirements
PASI Score Documentation Disease severity measurement required Clinical notes PASI Guidelines
Appeal Deadline (Internal) 60 days from denial notice Member ID card CareFirst Appeals
External Review Deadline 120 days from final denial Form 216-A Virginia SCC

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Network Status

Who: Patient or clinic staff
Document needed: Insurance card, plan summary
Action: Call member services number on insurance card to confirm Tremfya coverage requirements
Timeline: Same day
Source: Anthem Member Services

2. Gather Required Clinical Documentation

Who: Prescribing physician
Documents needed: PASI scores, treatment history, diagnosis codes
Action: Document disease severity (PASI ≥10 or BSA >10%) and prior therapy failures
Timeline: 1-2 business days
Source: PASI Documentation Guidelines

3. Submit Prior Authorization Request

Who: Prescriber or clinic staff
Platform: Availity Essentials portal or fax to 844-512-7020
Documents: PA form, clinical notes, lab results
Timeline: Decision within 72 hours (24 hours if expedited)
Source: Anthem PA Process

4. Set Up Specialty Pharmacy

Who: Patient with clinic coordination
Action: Transfer prescription to in-network specialty pharmacy
Options: CVS Specialty, BioPlus, CenterWell, others
Timeline: 2-3 business days for setup
Source: BCBS Specialty Pharmacy Network

5. Monitor Authorization Status

Who: Patient and clinic
Action: Check approval status via provider portal or member services
Follow-up: If denied, immediately begin appeal process
Timeline: Ongoing monitoring

Required Forms and Documentation

Prior Authorization Forms

Anthem Blue Cross Blue Shield Virginia requires specific documentation for Tremfya prior authorization requests. The exact form varies by plan, but all requests must include:

  • Patient demographics and insurance information
  • Prescriber details and NPI number
  • Diagnosis codes (ICD-10: L40.0 for plaque psoriasis, L40.5 for psoriatic arthritis)
  • Clinical justification with PASI scores and treatment history
Tip: Download the most current PA form from the Anthem provider portal rather than using cached versions, as requirements change frequently.

Medical Necessity Documentation

Your physician must provide comprehensive clinical documentation including:

  • Disease severity measures: PASI score ≥10 or BSA >10% for systemic therapy consideration
  • Prior treatment history: Detailed records of topical therapies, conventional systemic agents, and any previous biologics
  • Treatment failures: Specific reasons why preferred formulary agents are inappropriate (ineffective, contraindicated, or caused adverse effects)
  • Clinical rationale: Evidence-based justification for Tremfya selection

Specialty Pharmacy Network Requirements

Blue Cross Blue Shield Virginia requires Tremfya to be dispensed through designated specialty pharmacies. For self-administered injections, approved options include:

  • CVS Specialty (primary medical benefit pharmacy)
  • BioPlus Specialty Pharmacy
  • CenterWell Pharmacy
  • Inova Retail and Specialty Pharmacy
  • MedStar Specialty Pharmacy
Important: Using an out-of-network pharmacy may result in no coverage, leaving you responsible for the full cost of treatment.

Pharmacy Setup Process

  1. Prescription transfer: Your doctor sends the prescription directly to your chosen specialty pharmacy
  2. Insurance verification: The pharmacy confirms coverage and copay information
  3. Patient onboarding: Complete intake forms and schedule delivery
  4. Ongoing support: Access to pharmacist consultations and adherence monitoring

Counterforce Health helps patients navigate complex specialty pharmacy requirements and can assist with transferring prescriptions when authorization issues arise.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient disease severity Provide PASI scores and BSA measurements Clinical assessment with objective measures
Step therapy not completed Document failures/contraindications to preferred agents Treatment history with specific outcomes
Missing TB screening Complete required testing QuantiFERON results, chest X-ray
Quantity limits exceeded Justify dosing based on FDA labeling Prescriber letter referencing approved dosing
Not medically necessary Provide clinical guidelines supporting use AAD or NCCN guideline citations

Clinician Corner: Medical Necessity Letter Checklist

When writing a medical necessity letter for Tremfya, include:

✓ Patient problem: Specific diagnosis with ICD-10 codes
✓ Disease severity: PASI score, BSA involvement, impact on quality of life
✓ Prior treatments: Detailed history of topical agents, phototherapy, systemic treatments
✓ Treatment outcomes: Specific reasons for discontinuation (ineffective, adverse effects, contraindications)
✓ Clinical rationale: Why Tremfya is the appropriate next step
✓ Guideline support: Reference AAD psoriasis guidelines or FDA labeling
✓ Monitoring plan: Safety monitoring and efficacy assessment timeline

Appeals Process for BCBS Virginia

If your Tremfya prior authorization is denied, Virginia law provides multiple levels of appeal:

Internal Appeal (Redetermination)

  • Deadline: 60 days from denial notice
  • Submission: Online portal, fax, mail, or phone
  • Timeline: Decision within 30 days (72 hours if urgent)
  • Required documents: Denial letter, additional clinical evidence, prescriber support letter

Expedited Internal Appeal

  • When to use: Delay could seriously jeopardize health
  • Timeline: 72 hours for decision
  • Requirements: Physician certification of urgency

External Review (Virginia State)

After exhausting internal appeals, you can request external review through Virginia's State Corporation Commission:

  • Deadline: 120 days from final internal denial
  • Form: Form 216-A
  • Submission: Mail, fax (804-371-9915), or email to [email protected]
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Decision: Binding on insurer if overturned
Note: Virginia offers expedited external review for cancer treatments without requiring completion of internal appeals first, though this doesn't typically apply to psoriasis medications.

Medical Necessity Criteria

Plaque Psoriasis Requirements

Tremfya approval for plaque psoriasis typically requires documentation of:

  • Disease severity: PASI ≥10, BSA >10%, or involvement of special areas (face, hands, feet, genitals)
  • Failed topical therapy: Inadequate response to appropriate topical treatments
  • Systemic therapy indication: Patient is a candidate for systemic treatment per clinical guidelines

Psoriatic Arthritis Requirements

For psoriatic arthritis indications:

  • Active disease: Objective evidence of joint involvement
  • Inadequate response: Failed trial of conventional DMARDs like methotrexate
  • Clinical assessment: Documented active inflammation and functional impairment

Counterforce Health's platform analyzes denial letters and helps identify which specific medical necessity criteria need additional documentation for successful appeals.

Virginia External Review Process

Virginia's external review process provides an independent evaluation of insurance denials. Here's what you need to know:

Eligibility Requirements

  • Final denial from your insurance company
  • Denial based on medical necessity, appropriateness, or experimental/investigational determination
  • Virginia-issued insurance plan or self-funded plan that opts into state review

Required Documents for Form 216-A

  • Completed and signed Form 216-A
  • Copy of final denial letter
  • Insurance card copy
  • Signed medical records release
  • Any new supporting medical evidence

Contact Information

Virginia State Corporation Commission Bureau of Insurance
Address: P.O. Box 1157, Richmond, VA 23218
Phone: 1-877-310-6560
Fax: (804) 371-9915
Email: [email protected]

The SCC's decision is binding on both you and your insurer. If they overturn the denial, your insurer must provide coverage within 1-3 days.

Cost Savings and Patient Support

Manufacturer Support Programs

Janssen CarePath Savings Program

  • Eligible commercially insured patients may pay as little as $5 per dose
  • Income and insurance restrictions apply
  • Enrollment available at Tremfya.com

Foundation Assistance

  • Patient Advocate Foundation: Copay relief for qualifying patients
  • HealthWell Foundation: Financial assistance for autoimmune conditions
  • National Psoriasis Foundation: Resource directory for financial support

Frequently Asked Questions

How long does BCBS Virginia prior authorization take for Tremfya?
Standard decisions are made within 72 hours of receiving complete documentation. Expedited reviews are completed within 24 hours when delay could jeopardize health.

What if Tremfya is not on my formulary?
You can request a formulary exception by providing medical necessity documentation showing why preferred alternatives are inappropriate. Your physician must demonstrate clinical rationale for Tremfya specifically.

Can I get an expedited appeal in Virginia?
Yes, if your physician certifies that waiting for a standard review could seriously harm your health. Expedited internal appeals are decided within 72 hours, and expedited external reviews within 72 hours for urgent cases.

Does step therapy apply if I've tried biologics outside Virginia?
Treatment history from any location should count toward step therapy requirements. Provide complete medical records documenting prior therapy trials and outcomes.

What happens if my external review is denied?
The external review decision is final and binding. However, you retain rights to pursue legal action separately if you believe there were violations of law or contract terms.

How much does Tremfya cost without insurance?
List price varies but can exceed $20,000 annually. Patient assistance programs and manufacturer savings cards can significantly reduce out-of-pocket costs for eligible patients.

From our advocates: "We've seen many Virginia patients succeed with Tremfya appeals by focusing on special area involvement—like facial or genital psoriasis—even when their overall PASI score was under 10. The key is documenting how these locations impact quality of life and why topical treatments aren't sufficient. This composite tip reflects successful strategies, though individual outcomes vary."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals and prior authorization challenges, contact the Virginia State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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