By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Cigna in Virginia: PA Forms, Appeals, and Approval Timeline

Quick Answer: Getting Tremfya (Guselkumab) Covered by Cigna in Virginia

Tremfya requires prior authorization from Cigna and is typically placed on Tier 5 (specialty) with step therapy requirements. To get coverage in Virginia: 1) Have your doctor submit the Cigna PA form with TB screening, PASI scores, and documented failure of preferred biologics like adalimumab, 2) Enroll through Accredo specialty pharmacy (fax 888-302-1028), and 3) If denied, appeal within 180 days or request Virginia's external review via Form 216-A within 120 days.

Table of Contents

  1. Cigna Plan Types & Network Requirements
  2. Tremfya's Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Rules
  4. Specialty Pharmacy Setup Through Accredo
  5. Cost-Share Basics for Virginia Members
  6. Submission Process & Required Forms
  7. Common Approval Patterns
  8. Appeals Process in Virginia
  9. FAQ: Tremfya Coverage Questions
  10. Sources & Further Reading

Cigna Plan Types & Network Requirements

Your specific Cigna plan type affects how Tremfya coverage works in Virginia:

Commercial Plans (HMO/PPO/EPO)

  • HMO plans require referrals to specialists and may limit which dermatologists or rheumatologists can prescribe Tremfya
  • PPO plans offer more flexibility but may have higher out-of-network costs
  • All plan types require prior authorization for Tremfya

Medicare Advantage

  • Subject to additional Medicare Part D requirements
  • May have different formulary tiers than commercial plans
  • Step therapy protocols often more restrictive
Note: Virginia expanded Medicaid in 2019, reducing the uninsured rate to 6.4% by 2023. If you qualify for Medicaid, coverage rules differ significantly from commercial Cigna plans.

Tremfya's Formulary Status & Tier Placement

Tier 5 Specialty Drug Status Tremfya is classified as a Tier 5 specialty medication on Cigna's formulary, meaning:

  • Higher copays or coinsurance (often 25-40% of drug cost)
  • Mandatory specialty pharmacy dispensing
  • Quantity limits: typically 200mg per 28 days
  • Prior authorization required for all new starts

Covered Indications Cigna covers Tremfya for FDA-approved uses in adults:

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

Prior Authorization & Step Therapy Rules

Medical Necessity Criteria

For Psoriasis/Psoriatic Arthritis:

  • Confirmed diagnosis with objective measures (PASI score for psoriasis, joint counts for PsA)
  • Failed or contraindicated conventional therapies (methotrexate, topicals, phototherapy)
  • Required step therapy: Documented trial and failure of at least one TNF inhibitor (adalimumab, etanercept, infliximab, certolizumab, or golimumab)

Clinical Documentation Required:

  1. TB Screening: Current tuberculosis test within 12 months (TST, QuantiFERON-Gold, or T-SPOT.TB)
  2. Disease Severity: PASI score or percentage body surface area affected
  3. Prior Therapy Records: Specific drugs tried, duration, dosage, and reason for discontinuation
  4. Specialist Involvement: Prescription by or consultation with dermatologist/rheumatologist
Tip: Cigna's PA policy requires that switching between adalimumab brands (Humira, Amjevita, etc.) counts as only one TNF inhibitor trial.

Common Denial Reasons & Fixes

Denial Reason Fix Required Documentation Needed
Missing TB screening Current test results Lab report with date and interpretation
Insufficient disease severity PASI documentation Current PASI score or BSA percentage
Step therapy not met Prior biologic failure Progress notes showing drug, duration, outcome
Non-specialist prescriber Specialist involvement Referral or consultation notes

Specialty Pharmacy Setup Through Accredo

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

Step-by-Step Accredo Enrollment

  1. Complete Enrollment Form: Download the Accredo Tremfya Prescription & Enrollment Form
  2. Gather Required Documents:
    • Front and back copies of insurance cards
    • Completed PA approval from Cigna
    • Patient contact information
  3. Submit to Accredo: Fax completed forms to 888-302-1028
  4. Patient Contact: Accredo will contact patient within 1-2 business days
  5. Tremfya withMe Program: Patients receive call from program guide at 833-948-4631
From our advocates: We've seen patients experience delays when they don't answer calls from "J&J withMe" numbers. These calls are legitimate and necessary for copay assistance enrollment and medication shipment coordination. Always answer or return these calls promptly to avoid treatment delays.

Copay Assistance Coordination

The Tremfya withMe Access Program offers:

  • Copay assistance: Pay as little as $0 per dose for eligible commercially insured patients
  • Bridge therapy: Free medication during insurance delays or appeals
  • Patient support: Dedicated guides for insurance navigation

Cost-Share Basics for Virginia Members

Typical Cigna Cost Structure for Tremfya:

  • Tier 5 coinsurance: 25-40% of negotiated price after deductible
  • Specialty deductible: May apply separately from medical deductible
  • Out-of-pocket maximum: Counts toward annual limit (verify with plan)
Note: This information is educational only. Actual costs depend on your specific plan design, deductible status, and copay assistance eligibility.

Submission Process & Required Forms

For Providers: PA Submission Checklist

Required Cigna Forms:

Submission Methods:

  • Online: CoverMyMeds portal or EHR integration
  • Fax: 1-866-873-8279 (verify current number)
  • Phone: 1-800-88CIGNA for urgent cases

Timeline Expectations:

  • Standard review: 72 hours for urgent, 15 days for non-urgent
  • Incomplete submissions add 5-10 days for additional information requests

Common Approval Patterns

Strong submissions typically include:

  1. Comprehensive clinical narrative explaining why Tremfya is medically necessary
  2. Detailed prior therapy timeline with specific outcomes and side effects
  3. Current disease activity measures (PASI scores, photographs, quality of life impacts)
  4. Guidelines citations supporting Tremfya use after TNF inhibitor failure
  5. Clear treatment goals and monitoring plan

Red flags that trigger denials:

  • Generic statements like "patient failed methotrexate" without specifics
  • Missing or outdated TB screening
  • Insufficient documentation of disease severity
  • Concurrent biologic therapy requests

Appeals Process in Virginia

If Cigna denies your Tremfya request, Virginia offers robust appeal rights:

Internal Appeals (Cigna)

  • Timeline: 180 days from denial notice
  • Levels: First-level and second-level internal reviews available
  • Expedited: 72 hours for urgent medical situations
  • Submit to: Cigna member portal or appeals department

Virginia External Review Process

After exhausting Cigna's internal appeals, Virginia's State Corporation Commission Bureau of Insurance provides external review:

Eligibility Requirements:

  • Final denial from Cigna's internal process
  • Denial based on medical necessity or experimental treatment
  • Virginia-issued plan or opted-in self-funded plan

How to Apply:

  1. Complete Form 216-A: External Review Request Form
  2. Gather Documents:
    • Final denial letter from Cigna
    • Copy of insurance card
    • Medical records supporting Tremfya necessity
  3. Submit Within 120 Days:
    • Mail: SCC Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218
    • Fax: (804) 371-9915
    • Email: [email protected]

Timeline & Process:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours (requires Form 216-C from physician)
  • Independent Review Organization (IRO) makes final binding decision
  • Success rate: Virginia doesn't publish specific statistics, but external reviews often succeed when clinical evidence is strong
Tip: Virginia's Office of the Managed Care Ombudsman (1-877-310-6560) can help navigate the external review process and is a free resource for consumers.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, identifying the specific coverage gaps, and drafting evidence-backed rebuttals that align with each payer's own policies. Our platform streamlines the appeals process by pulling the right clinical citations and formatting them according to payer requirements, helping reduce the back-and-forth that often delays patient access to necessary medications like Tremfya.

FAQ: Tremfya Coverage Questions

How long does Cigna prior authorization take for Tremfya in Virginia? Standard PA decisions are made within 15 days for non-urgent requests, 72 hours for urgent cases. Incomplete submissions extend this timeline.

What if Tremfya is non-formulary on my specific Cigna plan? Request a formulary exception with clinical justification. Cigna offers non-formulary override processes with additional documentation requirements.

Can I request expedited appeals in Virginia? Yes, if your physician certifies that delays could jeopardize your health. Use Form 216-C for Virginia external review expedited processing.

Does step therapy apply if I failed biologics outside Virginia? Yes, prior therapy history from any location counts toward step therapy requirements. Ensure you have complete records from previous providers.

How much will Tremfya cost with Cigna in Virginia? Costs vary by plan, but Tier 5 specialty drugs typically require 25-40% coinsurance. The Tremfya withMe copay program can reduce this to $0 for eligible patients.

What happens if external review upholds the denial? The IRO decision is final and binding. Consider consulting with a healthcare attorney or exploring alternative treatments with your physician.

When to Contact Counterforce Health

If you're facing a Tremfya denial from Cigna, our platform can help by automatically identifying the specific denial reasons and generating targeted appeals that address Cigna's exact policy requirements. We specialize in turning complex medical necessity arguments into clear, evidence-backed rebuttals that improve approval rates and reduce delays in patient care.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For personalized assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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