By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by Humana in California: Complete Requirements Checklist

Quick Answer: Getting Tremfya Covered by Humana in California

Eligibility: Humana requires prior authorization for Tremfya (guselkumab) with documented moderate-to-severe plaque psoriasis (≥3% body surface area) or active psoriatic arthritis, plus failed topical therapy and negative TB screening.

Fastest path: Submit Humana's PA form through their provider portal with complete medical necessity documentation, disease severity scores (PASI/IGA), and TB test results. Standard decisions take up to 30 days.

First step today: Contact your prescriber to gather prior treatment records and schedule TB screening if not done within the past year. California residents can appeal denials through Independent Medical Review (IMR) with 30-55% success rates for specialty biologics.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation
  5. Medical Necessity Letter Components
  6. Submission Process
  7. Specialty Pharmacy Requirements
  8. After Submission: What to Expect
  9. Appeals Process in California
  10. Common Denial Prevention Tips

Who Should Use This Checklist

This guide helps California residents with Humana Medicare Advantage or Part D plans who need Tremfya (guselkumab) for moderate-to-severe plaque psoriasis, psoriatic arthritis, or inflammatory bowel disease. You'll also find this useful if you've received a denial and need to understand the appeal process.

Expected outcome: With complete documentation, Humana's PA approval rate is relatively high—the insurer has one of the lowest denial rates among major Medicare plans at approximately 3.5%. However, denials that do occur often stem from incomplete documentation or missing step therapy requirements.

Member & Plan Basics

Coverage Requirements

  • Active Humana enrollment: Verify your plan includes prescription drug coverage (Part D or Medicare Advantage with integrated Part D)
  • Prior authorization mandatory: Tremfya requires PA approval before dispensing to avoid full cost responsibility
  • Specialty pharmacy network: Must use Humana's approved specialty pharmacy vendors
  • Deductible considerations: Specialty tier medications may have higher cost-sharing even after PA approval
Note: Check your Summary of Benefits to confirm specialty drug coverage details and any applicable deductibles.

Clinical Criteria Requirements

FDA-Approved Indications

Tremfya is approved for adults with:

  • Moderate-to-severe plaque psoriasis (subcutaneous: 100mg at weeks 0, 4, then every 8 weeks)
  • Active psoriatic arthritis (same dosing as psoriasis)
  • Moderately to severely active Crohn's disease (IV induction, then subcutaneous maintenance)
  • Moderately to severely active ulcerative colitis (IV induction, then subcutaneous maintenance)

Disease Severity Documentation

Condition Required Severity Markers Documentation Needed
Plaque Psoriasis ≥3% body surface area OR palmoplantar/facial/genital involvement PASI score, IGA score, clinical photos
Psoriatic Arthritis Active joint involvement Tender/swollen joint count, imaging results
Crohn's Disease CDAI score ≥220, SES-CD ≥6 Endoscopy results, symptom scores
Ulcerative Colitis Moderate-to-severe activity Colonoscopy findings, Mayo score

Step Therapy Requirements

Must document failure of (unless contraindicated):

  • Topical therapies: Corticosteroids (betamethasone, clobetasol), vitamin D analogs (calcipotriene), tazarotene, or calcineurin inhibitors
  • For IBD: Conventional therapy (corticosteroids, immunomodulators) or biologics
  • Duration: Include drug name, dates, and duration of failed trials

Safety Screening

  • TB screening mandatory: Interferon-Gamma Release Assay (IGRA) or Tuberculin Skin Test (TST) within past year
  • Active infections: Must be resolved before initiation
  • Live vaccines: Avoid during treatment

Coding & Documentation

ICD-10 Diagnosis Codes

  • Plaque psoriasis: L40.0 (psoriasis vulgaris)
  • Psoriatic arthritis: L40.50-L40.59 (psoriatic arthropathy)
  • Crohn's disease: K50.0-K50.9 series
  • Ulcerative colitis: K51.00-K51.911

HCPCS/Billing Codes

  • J-code: J1628 (injection, guselkumab, 1 mg)
  • NDC numbers: Verify current codes with specialty pharmacy
  • Units: Based on prescribed dose (100mg = 100 units)

Medical Necessity Letter Components

Required Elements for Prescriber Letter

  1. Patient demographics and Humana member ID
  2. Primary diagnosis with ICD-10 code
  3. Disease severity documentation:
    • Objective scores (PASI, IGA, CDAI)
    • Body surface area percentage
    • Functional impact assessment
  4. Prior treatment history:
    • Specific medications tried
    • Dates and duration of trials
    • Reasons for discontinuation
  5. Clinical rationale for Tremfya selection
  6. Dosing plan and treatment goals
  7. TB screening results with date
  8. Provider signature and credentials

Supporting Documentation Checklist

  • Complete medical records from past 12 months
  • Laboratory results (TB screening, baseline labs)
  • Imaging studies (if applicable for PsA or IBD)
  • Prior authorization forms from previous medications
  • Clinical photographs (for psoriasis)
  • Specialist consultation notes
From our advocates: We've seen the strongest approvals when providers include specific PASI or IGA scores rather than general descriptions like "moderate psoriasis." Quantifiable disease severity measures significantly improve approval odds, especially when combined with clear documentation of topical therapy failures.

Submission Process

Step-by-Step Submission

  1. Gather documentation (allow 3-5 business days)
  2. Complete Humana PA form using current version from provider portal
  3. Submit via preferred method:
    • Online: Humana provider portal (fastest processing)
    • Fax: Verify current number with Humana
    • Phone: For expedited requests only
  4. Record confirmation number and submission date
  5. Follow up if no response within 7-10 business days

Required Form Fields

  • Patient demographics and member ID
  • Prescriber information and NPI
  • Diagnosis codes and clinical justification
  • Prior therapy documentation
  • Requested medication details (strength, quantity, directions)

Specialty Pharmacy Requirements

Tremfya must be dispensed through Humana's approved specialty pharmacy network. Counterforce Health can help streamline this process by identifying the right specialty pharmacy partners and ensuring proper documentation transfer.

Pharmacy Transfer Steps

  1. Verify network status with Humana member services
  2. Contact preferred specialty pharmacy from approved list
  3. Authorize prescription transfer from current pharmacy
  4. Confirm insurance verification and PA status
  5. Schedule delivery with cold-chain requirements
  6. Coordinate injection training if needed

Available Support Programs

  • Tremfya withMe: Manufacturer support program for adherence and injection training
  • Copay assistance: May be available for eligible commercial patients
  • Financial hardship programs: Through manufacturer or specialty pharmacy

After Submission: What to Expect

Timeline Expectations

  • Standard PA decision: Up to 30 days from complete submission
  • Expedited review: 72 hours for urgent medical situations
  • Additional information requests: 7-14 days for provider response

Status Monitoring

  • Check Humana provider portal for real-time updates
  • Document all communication attempts and responses
  • Save confirmation numbers and reference IDs

Approval Actions

  • If approved: Prescription forwards to specialty pharmacy automatically
  • If denied: Review denial letter for specific reasons and appeal options
  • If pending: Respond promptly to any information requests

Appeals Process in California

California offers robust appeal rights through the Department of Managed Health Care (DMHC) Independent Medical Review (IMR) system.

Internal Appeal (First Level)

  • Timeline: Must file within 30 days of denial
  • Process: Submit appeal through Humana member portal or by mail
  • Decision timeframe: Up to 30 days (expedited: 72 hours)

Independent Medical Review (External Appeal)

  • Eligibility: After internal appeal denial or 30-day non-response
  • Success rates: 30-55% overturn rate for specialty biologics depending on plan
  • Timeline: 45 days for standard review, 7 days for expedited
  • Cost: No fee to patient

Filing an IMR

  1. Contact DMHC Help Center: (888) 466-2219
  2. Submit IMR application online at healthhelp.ca.gov
  3. Include all supporting documentation
  4. Track case status through DMHC portal
Tip: California's IMR system has independent physician experts review denials. Success rates are higher when appeals include peer-reviewed literature supporting off-label use or when standard therapies have failed.

Common Denial Prevention Tips

Top 5 Pitfalls to Avoid

  1. Incomplete TB screening documentation
    • Fix: Include test date, method (IGRA/TST), and negative result
  2. Vague disease severity descriptions
    • Fix: Provide specific PASI/IGA scores and body surface area percentages
  3. Missing step therapy documentation
    • Fix: List each prior medication with dates, duration, and failure reason
  4. Outdated PA forms
    • Fix: Always download current forms from Humana provider portal
  5. Insufficient clinical justification
    • Fix: Reference FDA labeling and clinical guidelines supporting Tremfya use

Documentation Best Practices

  • Use objective measures whenever possible
  • Include relevant clinical guidelines citations
  • Provide complete medication history with specific dates
  • Submit high-quality clinical photographs for psoriasis
  • Ensure all forms are signed and dated

Printable Checklist

Before Submission:

  • Current Humana PA form completed
  • Medical necessity letter with severity scores
  • TB screening results (within 12 months)
  • Prior therapy documentation with dates
  • ICD-10 codes verified
  • Supporting clinical notes attached

After Submission:

  • Confirmation number recorded
  • Follow-up date scheduled
  • Specialty pharmacy identified
  • Appeal timeline noted (if needed)

This information is for educational purposes only and does not constitute medical advice. Consult with your healthcare provider for personalized treatment recommendations.

For additional help navigating insurance coverage challenges, Counterforce Health provides specialized support for turning prescription drug denials into successful, evidence-backed appeals.

Sources & Further Reading

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