By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Cigna in Ohio: Complete PA Guide with Appeals and Timeline

Answer Box: Quick Path to Tremfya Coverage

Cigna requires prior authorization for Tremfya (guselkumab) in Ohio with mandatory step therapy through TNF inhibitors. Your dermatologist or specialist must submit the PA form with documented failure of at least one TNF inhibitor (like Humira), current TB screening, and disease severity measures. Standard approval takes 15 days; urgent cases get 72-hour review. If denied, you have 180 days to appeal internally, then can request external review through Ohio Department of Insurance within 180 days of final denial.

First step today: Download Cigna's Tremfya PA form from their provider portal and schedule specialist consultation if you haven't tried required step therapy medications.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Medical Necessity Criteria
  5. Costs and Specialty Pharmacy
  6. Denials and Appeals
  7. Reauthorization Schedule
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics

Is Tremfya Covered by Cigna?

Yes, Tremfya (guselkumab) is covered on Cigna's National Preferred Formulary, but requires prior authorization for all formulations (subcutaneous and intravenous). The medication is typically placed on a high specialty tier with step therapy requirements and quantity limits.

Which Cigna Plans Cover Tremfya in Ohio?

All Cigna commercial plans in Ohio follow the same prior authorization criteria, including:

  • Individual marketplace plans
  • Employer-sponsored group plans
  • Medicare Advantage plans (with additional Medicare-specific requirements)

Coverage follows Cigna's national inflammatory conditions policy, updated November 2024.

Prior Authorization Process

Who Submits the Prior Authorization?

Your prescribing physician or their staff submits the PA, not you as the patient. The medication must be prescribed by or in consultation with:

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

How to Submit

Three submission methods:

  1. Online: CoverMyMeds or SureScripts through EHR (preferred)
  2. Fax: 1-866-873-8279 (verify current number)
  3. Phone: 1-800-88CIGNA for urgent cases

Required Documentation

Your provider must include:

  • Current Cigna Tremfya PA form
  • Prescriber NPI number and patient demographics
  • Relevant ICD-10 diagnosis codes
  • Prior therapy documentation with specific dates and outcomes
  • Disease severity measures (PASI scores for psoriasis)
  • Current TB screening results (within 12 months)

Timing and Urgency

Review Type Timeline When to Use
Standard 15 days Routine new prescriptions
Urgent 72 hours Serious health risk or hospitalization
Expedited Appeal 72 hours Life-threatening situations

How to Check Status: Log into Cigna provider portal or call 1-800-88CIGNA with the PA reference number.

Medical Necessity Criteria

Step-by-Step Requirements

All patients must meet BOTH:

  1. Age requirement: ≥18 years (pediatric: ≥6 years and ≥40 kg)
  2. Specialist involvement: Prescribed by appropriate specialist

Plus indication-specific criteria:

For Plaque Psoriasis/Psoriatic Arthritis

  • Moderate-to-severe disease documented
  • Step therapy required: Trial and failure of at least one TNF inhibitor (adalimumab, etanercept, infliximab, certolizumab, or golimumab)
  • Current PASI score or body surface area percentage
  • TB screening within 12 months

For Crohn's Disease/Ulcerative Colitis

  • Patient ≥18 years
  • Trial/failure of conventional therapy (corticosteroids, immunomodulators) OR
  • Inadequate response to TNF inhibitors
  • Documentation of specific prior treatments with duration and outcomes
Note: Switching between adalimumab brands (Humira, Amjevita, etc.) counts as only one TNF inhibitor trial per Cigna's policy.

What Counts as Step Therapy Failure?

Acceptable documentation includes:

  • Inadequate clinical response after appropriate trial duration
  • Intolerable side effects requiring discontinuation
  • Medical contraindications to continued use
  • Loss of efficacy over time

Costs and Specialty Pharmacy

Understanding Your Costs

Tremfya costs vary significantly by plan design:

  • Specialty tier coinsurance: Typically 20-50% after deductible
  • Copay plans: May have fixed specialty copays ($100-500+ per month)
  • Deductible impact: High-deductible plans require meeting deductible first

Check your specific costs: Use Cigna's drug list tool at cigna.com or call the number on your ID card.

Manufacturer Support Options

  • Janssen CarePath: Provides copay assistance and patient support
  • Income-based programs: Available for eligible patients
  • Foundation grants: Check with specialty pharmacy for application assistance

Denials and Appeals

Common Denial Reasons and Solutions

Denial Reason How to Fix
Missing TB screening Submit current test results with interpretation
Step therapy not met Provide detailed TNF inhibitor trial documentation
Non-specialist prescriber Obtain dermatologist/specialist consultation
Insufficient disease severity Include current PASI scores or clinical photos
Incomplete prior therapy records Submit progress notes with specific drugs, doses, durations

Appeals Process in Ohio

Internal Appeals (with Cigna):

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for urgent
  • Required: Copy of denial, new supporting evidence, physician letter

External Review (Ohio Department of Insurance):

  • Deadline: 180 days from final Cigna denial
  • Timeline: 30 days for standard, 72 hours for urgent
  • Cost: Free to patients
  • Contact: Ohio Department of Insurance at 1-800-686-1526

The external review is conducted by an Independent Review Organization (IRO) with medical experts in the relevant specialty. Their decision is binding on Cigna.

From our advocates: "We've seen Tremfya appeals succeed when providers include detailed clinical narratives explaining why step therapy medications failed and how Tremfya specifically addresses the patient's treatment goals. Photos documenting disease severity and peer-reviewed studies supporting the treatment choice strengthen the case significantly."

Reauthorization Schedule

When to Renew Authorization

Initial approval: 6 months Continuation approval: 1 year (for patients established ≥6 months)

Continuation Requirements

Patients must demonstrate at least one of the following:

  • Objective clinical response (reduced inflammatory markers, improved imaging)
  • Symptom improvement (decreased pain, fatigue, joint stiffness)
  • Reduced need for corticosteroids
  • Maintained disease stability

Plan ahead: Submit renewal requests 30-45 days before expiration to avoid treatment gaps.

Specialty Pharmacy Requirements

Mandatory Network Pharmacy

Cigna requires Tremfya fills through Accredo (Express Scripts specialty arm) for most plans. Alternative options may include:

  • Gentry Health Services (limited distribution)
  • University Hospitals Cleveland Specialty Pharmacy (if available)

Ordering Process

For prescribers:

  • E-prescribe to Accredo (NCPDP 4436920, Memphis, TN)
  • Fax: 888-302-1028
  • Phone: 866-759-1557

Services included:

  • Free home delivery with temperature control
  • 24/7 pharmacist and nurse support
  • Injection training and adherence monitoring
  • Refill reminders via myCigna app

Troubleshooting Common Issues

Portal Problems

  • PA form not loading: Clear browser cache or try different browser
  • Submission errors: Verify all required fields completed, check file size limits
  • Status not updating: Allow 24-48 hours; call if still pending

Missing Forms or Information

  • Current PA forms: Download from Cigna provider resources
  • Policy updates: Check monthly policy update bulletins
  • Specialty pharmacy coordination: Accredo will contact patient after PA approval

Communication Issues

  • Provider-to-provider calls: Request peer-to-peer review if initial denial
  • Patient advocacy: Contact Cigna member services for coverage questions
  • Regulatory help: Ohio Department of Insurance consumer hotline

Frequently Asked Questions

How long does Cigna PA take for Tremfya in Ohio? Standard reviews take up to 15 days; urgent cases are decided within 72 hours. Incomplete submissions may add 5-10 days for additional information requests.

What if Tremfya is non-formulary on my plan? Submit a formulary exception request with clinical justification. Your doctor must demonstrate medical necessity and why preferred alternatives are inappropriate.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Submit Form 216-C to Ohio Department of Insurance for 72-hour expedited external review.

Does step therapy apply if I failed TNF inhibitors in another state? Yes, prior therapy documentation from any state counts toward step therapy requirements. Ensure complete medical records are submitted.

What happens if I miss my reauthorization deadline? Treatment may be interrupted. Contact your specialty pharmacy immediately to expedite renewal and request emergency supplies if available.

How do I find Ohio-specific Cigna coverage policies? Cigna uses national policies that apply uniformly across states. Check the Cigna provider portal for current policies.

Can I appeal if my doctor isn't a specialist? Yes, but you'll need specialist consultation or referral. The appeal should include documentation of specialist involvement in treatment decisions.

What if Accredo can't fill my prescription? Contact Cigna to verify specialty pharmacy network options. Some limited distribution drugs may have alternative approved pharmacies.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed rebuttal letters. The platform analyzes denial reasons and drafts point-by-point responses aligned to each plan's specific policies and procedural requirements.

If you're navigating a complex Tremfya approval or appeal in Ohio, Counterforce Health's automated system can help identify the specific denial basis and generate comprehensive appeals documentation that meets Cigna's requirements and Ohio's regulatory standards.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult your healthcare provider and insurance company for personalized guidance. For official Ohio insurance regulations and consumer assistance, contact the Ohio Department of Insurance at 1-800-686-1526.

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