By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Cigna in New York: Complete Prior Authorization Guide

Quick Answer: Getting Tremfya Covered by Cigna in New York

Eligibility: Tremfya requires prior authorization through Cigna for adults with moderate-to-severe plaque psoriasis, psoriatic arthritis, or Crohn's disease. Fastest path: Have your specialist submit a complete prior authorization with documented disease severity (PASI ≥10 for psoriasis), prior therapy failures, and clinical rationale through CoverMyMeds or call 1-800-882-4462. First step today: Contact your dermatologist, rheumatologist, or gastroenterologist to initiate the PA process and gather your treatment history documentation.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Information
  5. Documentation Requirements
  6. Submission Process
  7. Specialty Pharmacy Setup
  8. After Submission: What to Expect
  9. Appeals Process in New York
  10. Common Denial Reasons & Solutions
  11. Costs & Patient Support Programs
  12. Frequently Asked Questions

Who Should Use This Guide

This checklist is designed for New York residents with Cigna coverage who need Tremfya (guselkumab) for:

  • Moderate-to-severe plaque psoriasis
  • Active psoriatic arthritis
  • Moderately to severely active Crohn's disease
  • Ulcerative colitis (maintenance therapy)

Expected outcome: With proper documentation, most prior authorizations are approved within 72 hours. If initially denied, New York's robust external appeal process provides additional pathways to coverage.

Member & Plan Basics

Coverage Requirements

  • Active Cigna coverage with prescription benefits
  • Prior authorization required for all Tremfya formulations
  • Specialty pharmacy enrollment typically through Express Scripts/Accredo
  • Specialist prescriber required (dermatologist, rheumatologist, or gastroenterologist)
Note: Cigna manages specialty drugs through Express Scripts, with Accredo as the preferred specialty pharmacy for Tremfya in most plans.

Plan Types Covered

  • Commercial employer plans
  • Individual/family plans through NY State of Health
  • Medicare Advantage (with additional Medicare-specific requirements)
  • Some Medicaid managed care plans

Clinical Criteria Requirements

For Plaque Psoriasis

  • Age: 18 years or older
  • Disease severity: PASI ≥10 OR BSA >10% OR involvement of face, hands, feet, or genitals
  • Prior therapy failures: Must have tried or have contraindications to:
    • Topical corticosteroids
    • At least one traditional systemic agent (methotrexate, cyclosporine, or acitretin)
  • Specialist requirement: Prescribed by or in consultation with a dermatologist

For Psoriatic Arthritis

  • Confirmed diagnosis of active psoriatic arthritis
  • Prior therapy: Failed or contraindicated conventional DMARDs
  • Specialist requirement: Rheumatologist involvement

For Inflammatory Bowel Disease (Crohn's/UC)

  • Confirmed diagnosis with appropriate severity
  • Prior therapy: Failed conventional treatments or biologics (plan-dependent)
  • Specialist requirement: Gastroenterologist involvement

Coding & Billing Information

Condition ICD-10 Codes HCPCS J-Code Example NDCs
Plaque Psoriasis L40.0 J1628 57894-640-01, 57894-640-02
Psoriatic Arthritis L40.50-L40.59 J1628 57894-640-01, 57894-640-02
Crohn's Disease K50.00-K50.919 J1628 57894-640-01, 57894-640-02

Dosing: 100 mg subcutaneous at weeks 0, 4, then every 8 weeks for all approved indications.

Documentation Requirements

Medical Necessity Letter Must Include:

  • Patient demographics and insurance information
  • Primary diagnosis with ICD-10 code
  • Disease severity documentation:
    • PASI score for psoriasis
    • Joint involvement for psoriatic arthritis
    • Disease activity scores for IBD
  • Complete prior therapy history with:
    • Drug names and dates
    • Duration of treatment
    • Reason for discontinuation (ineffective, intolerance, contraindication)
  • Clinical rationale for Tremfya selection
  • Monitoring plan for safety and efficacy
  • Provider signature and NPI number

Required Attachments:

  • Recent clinical notes (within 6 months)
  • Laboratory results (if applicable)
  • Imaging studies (if relevant)
  • Prior authorization forms from other therapies (if applicable)
Clinician Corner: Download the official Tremfya Letter of Medical Necessity template from Janssen to ensure all required elements are included.

Submission Process

Electronic Prior Authorization (Preferred)

  1. CoverMyMeds: Primary platform for Cigna PA submissions
  2. EviCore by Evernorth: Select "Pharmacy Drugs (Express Scripts Coverage)"
  3. Phone submission: 1-800-882-4462 if electronic submission unavailable

Required Fields:

  • Patient demographics (name, DOB, member ID)
  • Prescriber information with NPI
  • Drug details (name, strength, quantity, frequency)
  • Diagnosis code (ICD-10)
  • Medical necessity documentation
  • Specialist consultation notes

Processing Timeline:

  • Standard review: 72 hours
  • Expedited review: 24 hours (urgent cases)
  • Incomplete submissions: Additional 72 hours after information provided

Specialty Pharmacy Setup

Cigna's Preferred Network:

  • Primary: Accredo Specialty Pharmacy
  • Enrollment: Call 844-516-3319 or use online referral form
  • New York requirements: Electronic prescribing mandatory (rare exemptions only)

Transfer Process:

  1. Provider submits completed Accredo enrollment form
  2. Patient verification of insurance and shipping address
  3. Prescription transfer coordination between pharmacies
  4. Shipment setup for home or office delivery
Tip: Use the myCigna portal or Accredo patient portal to track prescription status and manage refills.

After Submission: What to Expect

Approval Notifications:

  • Provider: Electronic notification through submission portal
  • Patient: Letter or portal notification
  • Pharmacy: Direct authorization for dispensing

If Additional Information Needed:

  • Response deadline: 72 hours to avoid denial
  • Common requests: Additional lab results, specialist notes, or clarification of prior therapies

Confirmation Numbers:

  • Record: PA confirmation number
  • Duration: Approvals typically valid for 6-12 months
  • Renewal: Submit renewal request 30 days before expiration

Appeals Process in New York

Internal Appeal (First Level)

  • Timeline: File within 180 days of denial
  • Process: Submit through Cigna member portal or call member services
  • Decision: Within 30 days (expedited: 72 hours for urgent)

External Review (New York State)

  • Eligibility: After final internal denial
  • Timeline: Request within 4 months through NY Department of Financial Services
  • Cost: Maximum $25 (waived for Medicaid or financial hardship)
  • Decision: Binding on Cigna if approved

New York-Specific Rights:

  • Expedited external appeals: 72 hours for urgent (24 hours for urgent drug denials)
  • Independent medical review: Assigned by NY DFS
  • Consumer assistance: Community Health Advocates helpline at 888-614-5400

For external appeals, visit the NY DFS External Appeal Portal or call 1-800-400-8882.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient disease severity Document PASI ≥10 or BSA >10% Clinical assessment, photos if available
Missing prior therapy trials Provide complete treatment history Pharmacy records, provider notes
Non-specialist prescriber Transfer to appropriate specialist Referral to dermatologist/rheumatologist/GI
Incomplete medical necessity Submit detailed clinical rationale Comprehensive letter with guidelines cited
Quantity/frequency limits Justify FDA-approved dosing FDA labeling, clinical guidelines

Costs & Patient Support Programs

Manufacturer Support:

  • Janssen CarePath: Copay assistance up to $20,000/year for eligible patients
  • Eligibility: Commercial insurance (not Medicare/Medicaid)
  • Application: JanssenCarePath.com or call 1-877-CarePath

Additional Resources:

  • Patient Advocate Foundation: Copay relief program
  • HealthWell Foundation: Financial assistance for qualifying patients
  • State pharmaceutical assistance: New York EPIC program for seniors

Frequently Asked Questions

How long does Cigna prior authorization take for Tremfya in New York? Standard review is 72 hours; expedited review for urgent cases is 24 hours. Incomplete submissions may take additional time.

What if Tremfya is non-formulary on my Cigna plan? Request a formulary exception with medical necessity documentation. Your doctor must demonstrate why preferred alternatives are inappropriate.

Can I get an expedited appeal in New York? Yes, New York allows expedited external appeals with decisions in 72 hours (24 hours for urgent drug denials) when health is at serious risk.

Does step therapy apply if I failed treatments outside New York? Yes, documented treatment failures from any state count toward step therapy requirements if properly documented.

What happens if my appeal is denied by Cigna? You can request an external review through the New York Department of Financial Services within 4 months. Their decision is binding on Cigna.

Do I need to use Accredo for Tremfya? Most Cigna plans require use of their preferred specialty pharmacy network. Check your specific plan requirements.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements, significantly improving approval rates for complex specialty medications like Tremfya.

From Our Advocates: We've seen many Tremfya appeals succeed when patients provide comprehensive documentation of disease severity and prior treatment failures. The key is often including objective measures like PASI scores and detailed pharmacy records showing adequate trials of step therapy medications. This composite guidance reflects successful strategies across multiple cases, though individual outcomes may vary.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by individual payers based on specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For additional help with insurance appeals in New York, contact Counterforce Health or the Community Health Advocates helpline at 888-614-5400.

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