By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Cigna in Illinois: Complete PA Guide and Appeal Timeline

Answer Box: Getting Tremfya Covered by Cigna in Illinois

Who qualifies: Adults with moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis who meet Cigna's clinical criteria. Fastest approval path: Submit prior authorization through your specialist (dermatologist for psoriasis, gastroenterologist for IBD) with documentation of prior therapy trials and disease severity. First step today: Contact your prescriber to request the Cigna Tremfya prior authorization form and gather records of previous treatments. Illinois residents have strong appeal rights with 30-day external review deadlines.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Medical Coding Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Setup
  8. After Submission: Tracking Your Request
  9. Appeals Process for Illinois
  10. Common Denial Reasons & Solutions
  11. Cost Support Options
  12. Printable Checklist

Who Should Use This Guide

This guide helps Illinois residents with Cigna insurance navigate the prior authorization process for Tremfya (guselkumab), a specialty biologic medication. You'll benefit from this resource if you:

  • Have moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis
  • Need to start Tremfya or transfer from another specialty pharmacy
  • Received a denial and want to appeal
  • Are a healthcare provider submitting on behalf of patients

Expected outcome: Following this guide should result in faster approval times and fewer denials. When appeals are needed, Illinois law provides strong patient protections with independent physician review.

Member & Plan Basics

Active Coverage Requirements

Before starting the prior authorization process, verify:

  • Active Cigna coverage through your member portal or ID card
  • Specialty pharmacy benefits (Tremfya requires specialty dispensing through Accredo)
  • Deductible status (specialty medications may have separate deductibles)
  • Plan type (commercial, Medicare Advantage, or Medicaid managed care)
Tip: Call the member services number on your Cigna ID card to confirm your specialty drug benefits and any applicable copays before starting the PA process.

Authorization Requirements by Indication

Cigna requires prior authorization for all Tremfya formulations (subcutaneous and intravenous). The medication must be prescribed by or in consultation with a specialist:

  • Psoriasis/Psoriatic Arthritis: Dermatologist or rheumatologist
  • Crohn's Disease/Ulcerative Colitis: Gastroenterologist

Clinical Criteria for Approval

Psoriasis Requirements

For initial therapy, patients must be ≥18 years old and meet ONE of the following criteria:

  • Tried or currently taking corticosteroids, OR corticosteroids are contraindicated
  • Tried at least one traditional systemic agent (methotrexate, cyclosporine, or acitretin) for ≥3 months, unless intolerant
  • Prescribed by or in consultation with a dermatologist

For continuation therapy (after 6 months), patients must demonstrate:

  • Beneficial clinical response using objective measures (PASI score improvement, BSA reduction)
  • Evidence of improved disease severity

Inflammatory Bowel Disease Requirements

For Crohn's disease and ulcerative colitis, patients must be:

  • ≥18 years old
  • Prescribed by or in consultation with a gastroenterologist
  • For IV induction: Initial approval covers three doses (three months)
  • For continuation: Must show beneficial clinical response using objective measures like fecal markers

Medical Coding Requirements

ICD-10 Codes

Psoriasis:

  • L40.0: Psoriasis vulgaris (plaque psoriasis)
  • L40.8: Other psoriasis
  • L40.9: Psoriasis, unspecified

Psoriatic Arthritis:

  • L40.50: Arthropathic psoriasis, unspecified
  • L40.51: Distal interphalangeal psoriatic arthropathy
  • L40.52: Psoriatic arthritis mutilans
  • L40.53: Psoriatic spondylitis

IBD Codes: Crohn's disease codes typically fall under K50 category (verify current codes with your billing department).

HCPCS and NDC Information

For billing purposes, verify current HCPCS J-codes with your pharmacy benefits manager. Tremfya NDC numbers and billing codes are available through Janssen's reimbursement support.

Documentation Packet Checklist

Provider Note Requirements

Your specialist's clinical note should include:

  • Diagnosis with ICD-10 code
  • Disease severity assessment (PASI score for psoriasis, clinical activity measures for IBD)
  • Prior therapy documentation: What was tried, duration, outcome, and reason for discontinuation
  • Contraindications to preferred agents (if applicable)
  • Treatment goals and expected outcomes
  • Dosing rationale and administration plan

Medical Necessity Letter Components

A strong letter of medical necessity should address:

  1. Patient-specific clinical presentation
  2. Evidence-based treatment rationale with guideline citations
  3. Prior therapy failures with specific details
  4. Why Tremfya is appropriate for this patient
  5. Monitoring plan and safety considerations
Clinician Corner: Include objective measures like baseline PASI scores (typically ≥12 for severe psoriasis), body surface area involvement, and impact on quality of life. Reference FDA labeling and relevant specialty society guidelines.

Required Attachments

  • Recent clinic notes (within 90 days)
  • Laboratory results (TB screening, hepatitis panel, CBC)
  • Prior therapy documentation
  • Insurance card and demographic information

Submission Process

Correct Forms and Portals

  1. Download the current PA form: Use Cigna's Tremfya prior authorization form
  2. Submit electronically: Use CoverMyMeds or SureScripts through your EHR when possible
  3. Alternative submission: Fax to the number listed on the PA form (verify current fax number)

Common Rejection Reasons

Avoid these frequent submission errors:

  • Incomplete forms: Missing prescriber NPI or patient demographics
  • Wrong specialist: Non-dermatologist prescribing for psoriasis
  • Missing documentation: No evidence of prior therapy trials
  • Outdated forms: Using previous year's PA form

Specialty Pharmacy Setup

Cigna requires Tremfya to be dispensed through Accredo specialty pharmacy. Here's the enrollment process:

Accredo Enrollment Steps

  1. Complete referral form: Download the Tremfya referral form
  2. Submit prescription information: Include dosing, quantity, and refills
  3. Patient enrollment: Accredo will contact the patient to verify insurance and shipping preferences
  4. Coordinate delivery: Medication ships to patient's preferred location
Note: The enrollment process typically takes 3-5 business days after PA approval. Accredo provides specialty-trained pharmacists for patient education and support.

After Submission: Tracking Your Request

Timeline Expectations

  • Standard review: 15 business days for non-urgent requests
  • Expedited review: 24-72 hours if medically urgent
  • Confirmation: Save your submission confirmation number

Status Checking

  • Provider portal: Check status through Cigna's provider portal
  • Phone: Call Cigna provider services with the PA reference number
  • Patient tracking: Patients can check status through their member portal

Appeals Process for Illinois

Illinois provides strong patient protections for insurance denials. Here's your appeal pathway:

Internal Appeals (Required First Step)

Timeline: Must file within 180 days of denial for providers, 60 days for members

Process:

  1. Submit Cigna appeal form
  2. Include denial letter and additional clinical documentation
  3. Cigna has 30 days for medical necessity appeals, 60 days for administrative appeals

External Review (Illinois-Specific)

If internal appeals fail, Illinois law guarantees independent external review:

Key Illinois Requirements:

  • 30-day deadline: Must request external review within 30 days of final denial (shorter than many states)
  • Independent physician review: Board-certified specialist in your condition
  • Binding decision: If approved, Cigna must cover the treatment
  • No cost: Illinois insurers pay for external review

How to Request: Contact the Illinois Department of Insurance at 877-527-9431 or use forms from their website.

From our advocates: We've seen many Tremfya denials overturned on appeal when providers submit comprehensive documentation showing failed prior therapies and disease severity measures. The key is demonstrating medical necessity with objective clinical data rather than general statements about treatment failure.

When to Escalate

Contact Illinois regulators if you experience:

  • Delayed appeal processing beyond legal timeframes
  • Repeated denials without clinical justification
  • Procedural violations in the review process

Illinois Department of Insurance Consumer Helpline: 877-527-9431 Illinois Attorney General Health Care Bureau: 877-305-5145

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing disease severity Submit objective measures PASI scores, BSA involvement, photos
No step therapy documentation Provide trial history Prescription records, clinic notes showing failures
Wrong prescriber specialty Get specialist consultation Referral letter or co-signature from appropriate specialist
Incomplete TB screening Submit required labs TB skin test, chest X-ray, interferon-gamma release assay
Non-formulary status Request formulary exception Medical necessity letter explaining why preferred agents failed

Cost Support Options

Manufacturer Support

Janssen CarePath: Offers copay assistance and insurance navigation support

  • Copay card: May reduce out-of-pocket costs for eligible patients
  • Prior authorization support: Free assistance with PA submissions
  • Website: Janssen CarePath for Tremfya

Additional Resources

  • Patient advocacy organizations: National Psoriasis Foundation, Crohn's & Colitis Foundation
  • State prescription assistance: Illinois may have additional programs for qualifying residents
  • Foundation grants: Various patient assistance foundations provide medication grants

Printable Checklist

Before Submitting PA:

  • Active Cigna coverage verified
  • Appropriate specialist involved (dermatologist/gastroenterologist)
  • Current PA form downloaded
  • ICD-10 codes documented
  • Prior therapy trials documented with dates and outcomes
  • Disease severity measures included (PASI, clinical assessments)
  • TB screening completed and documented
  • Patient demographic information complete

After Submission:

  • Confirmation number saved
  • Follow-up date scheduled (15 business days)
  • Accredo enrollment initiated
  • Patient informed of timeline and next steps

If Denied:

  • Denial letter reviewed for specific reasons
  • Additional documentation gathered
  • Appeal submitted within 180 days (providers) or 60 days (members)
  • External review option explained to patient

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, pulling the right clinical evidence and weaving it into appeals that meet procedural requirements while tracking deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance requirements change frequently. Always verify current policies with Cigna and consult your healthcare provider for medical decisions. For assistance with Illinois insurance issues, contact the Illinois Department of Insurance at 877-527-9431.

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