By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Cigna in Florida: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Tremfya (Guselkumab) Covered by Cigna in Florida

Cigna requires prior authorization for Tremfya with step therapy through traditional agents (methotrexate, cyclosporine) or TNF inhibitors for 3+ months. If denied, you have 180 days to file an internal appeal, with 30-day review times for future treatments. External review through Florida Department of Financial Services is available after internal exhaustion. First step today: gather your PASI score, prior therapy records, and TB screening results, then submit via Cigna's provider portal.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Cigna provider portal or fax (855) 840-1678 Cigna PA Policy
Age Requirement ≥18 years (≥6 years for pediatric PsA) Patient chart Coverage Criteria
Specialist Required Dermatologist, rheumatologist, or gastroenterologist Provider credentials PA Requirements
Step Therapy Traditional systemic agents OR TNF inhibitors (3+ months) Treatment history records Step Therapy Policy
Disease Severity PASI ≥10 OR BSA ≥3% OR significant functional impact PASI assessment, photos Medical Necessity
TB Screening Required before initiation Lab results, chest X-ray Safety Requirements

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

  • PASI score ≥10 or BSA ≥3% documentation
  • Records of failed therapies (methotrexate, cyclosporine, or TNF inhibitors for 3+ months)
  • TB screening results (QuantiFERON-Gold or tuberculin skin test + chest X-ray)
  • Timeline: 1-2 days to collect records

2. Submit Prior Authorization (Clinic)

  • Use Cigna PA forms or CoverMyMeds
  • Include ICD-10 codes, specialist notes, and treatment history
  • Submit via provider portal or fax (855) 840-1678
  • Timeline: Standard 5 business days for decision

3. If Denied, Request Peer-to-Peer (Clinic)

  • Call Cigna at 1-800-882-4462 within 48 hours of denial
  • Schedule discussion with medical director
  • Timeline: 24-48 hours for scheduling, same-day decision

4. File Internal Appeal if Still Denied (Patient or Clinic)

  • Submit within 180 days of denial notice
  • Include additional evidence and medical necessity letter
  • Timeline: 30 days for pre-service appeals

5. External Review if Internal Appeal Fails (Patient)

  • File with Florida DFS within 4 months of final denial
  • Call 1-877-MY-FL-CFO (1-877-693-5236) for assistance
  • Timeline: Free external review with binding decision

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
"Step therapy not completed" Document 3+ months of failed conventional therapy Prescription records, provider notes showing inadequate response or intolerance
"Insufficient disease severity" Submit PASI score ≥10 or BSA ≥3% PASI assessment form, clinical photos, functional impact documentation
"Missing TB screening" Complete required testing QuantiFERON-Gold or TST results, chest X-ray report
"Not prescribed by specialist" Get referral or specialist consultation Dermatologist, rheumatologist, or gastroenterologist prescription
"Concurrent biologic use" Discontinue other biologics Medication list showing no concurrent TNF inhibitors or IL-17 blockers

Appeals Playbook for Cigna in Florida

Internal Appeals (Level 1 & 2)

  • Filing deadline: 180 days from denial notice
  • How to submit: Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422 or provider portal
  • Required elements: Member ID, claim number, medical necessity justification, prescriber letter
  • Timeline: 30 days for pre-service, 60 days for post-service
  • Expedited option: 72 hours for urgent cases (call 1-800-88-CIGNA and mark "EXPEDITED - URGENT")

External Review via Florida DFS

  • Eligibility: After exhausting internal appeals for medical necessity denials
  • Filing deadline: 4 months from final internal denial
  • How to file: Call 1-877-MY-FL-CFO or submit online at Florida DFS portal
  • Cost: Free to consumers
  • Decision: Binding if favorable to patient
From our advocates: "We've seen Cigna approvals increase significantly when providers include specific PASI improvement targets and cite the FDA label's efficacy data in their medical necessity letters. The key is connecting disease severity to functional impact—not just numbers on a page."

Medical Necessity Documentation

Clinician Corner: Essential Elements for Your Letter

Problem Statement

  • Current PASI score and BSA involvement
  • Functional limitations (work, sleep, social activities)
  • Psychological impact of visible lesions

Prior Treatment History

  • Specific agents tried: methotrexate (dose, duration, response)
  • TNF inhibitor failures: adalimumab, etanercept, infliximab
  • Reasons for discontinuation: inadequate response, intolerance, contraindications

Clinical Rationale for Tremfya

  • IL-23 p19 inhibition mechanism for refractory psoriasis
  • FDA-approved dosing: 100mg SC at weeks 0, 4, then every 8 weeks
  • Safety profile compared to TNF inhibitors

Guideline Citations

When to Request Peer-to-Peer Review

Call 1-800-882-4462 (Cigna Health Services) to schedule a peer-to-peer discussion when:

  • Initial PA is denied despite meeting step therapy requirements
  • Medical director needs clarification on disease severity
  • Patient has contraindications to preferred alternatives

Phone Script for Providers: "I'm requesting a peer-to-peer review for [patient name] who was denied Tremfya coverage. The patient has failed methotrexate and adalimumab per your policy requirements, with current PASI score of [X]. I'd like to discuss the medical necessity with your reviewing physician."

Preparation Checklist:

  • Patient's treatment timeline with specific dates
  • PASI scores before/after each therapy
  • Contraindications to step therapy alternatives
  • Cigna's coverage policy printed for reference

Costs & Patient Assistance Options

Manufacturer Support

  • Janssen CarePath: Up to $20,000 annually in copay assistance for eligible patients
  • Eligibility: Commercial insurance (not Medicare/Medicaid), income restrictions apply
  • How to apply: JanssenCarePath.com or 1-877-CarePath

Foundation Grants

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

State Programs

  • Florida's pharmaceutical assistance programs through Department of Health
  • Medicaid coverage for eligible low-income residents

Counterforce Health helps patients navigate these assistance programs while simultaneously working on insurance appeals, ensuring you have coverage options during the approval process. Our platform connects patients with the right financial resources while building evidence-backed appeals that turn denials into approvals.

When to Escalate to State Regulators

Contact the Florida Department of Financial Services if:

  • Cigna violates appeal deadlines (30+ days for standard review)
  • Denial appears to contradict their own published policy
  • Pattern of inappropriate denials for your condition

Contact Information:

What to Include in Your Complaint:

  • Policy number and member ID
  • Denial letters and appeal correspondence
  • Timeline of events with specific dates
  • How Cigna's decision violates Florida insurance law

Frequently Asked Questions

How long does Cigna prior authorization take in Florida? Standard PA decisions take 5 business days. Expedited reviews for urgent cases are completed within 72 hours. Source: Cigna PA Policy

What if Tremfya is non-formulary on my plan? Request a formulary exception through Cigna's pharmacy benefit manager. You'll need medical necessity documentation showing why formulary alternatives are inappropriate.

Can I request an expedited appeal in Florida? Yes, if delay would seriously jeopardize your health. Call 1-800-88-CIGNA and request expedited review. Decision required within 72 hours.

Does step therapy apply if I failed TNF inhibitors outside Florida? Yes, out-of-state treatment records count toward step therapy requirements. Ensure your new Florida provider has complete medical records.

What's the success rate for Tremfya appeals in Florida? While specific data isn't published, external reviews in Florida have historically favored patients when proper medical evidence is submitted, especially for specialty drugs with clear FDA indications.

How much does external review cost in Florida? External review through Florida DFS is completely free to consumers. Source: Florida DFS

Can I use Tremfya with other biologics? No, Cigna's policy prohibits concurrent use with other biologics or targeted synthetic DMARDs due to infection risk.

What if I'm switching from another state's Medicaid? Florida Medicaid has its own formulary and PA requirements. You'll need to restart the approval process with Florida-specific documentation.

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan documents for the most current requirements. Coverage policies may change.

Sources & Further Reading

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