By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by UnitedHealthcare in Michigan: Prior Authorization, Appeals, and Coding Guide

Answer Box: Getting Tremfya Covered by UnitedHealthcare in Michigan

UnitedHealthcare requires prior authorization for Tremfya (guselkumab) through OptumRx, with step therapy requirements for most indications. Michigan residents have strong appeal rights through DIFS if denied. Your fastest path to approval: 1) Gather documentation of failed TNF inhibitors or conventional therapies, 2) Submit PA request with specialist prescription and ICD-10 codes (L40.0 for plaque psoriasis, L40.5x for psoriatic arthritis), 3) If denied, file internal appeal within 180 days, then external review with Michigan DIFS within 127 days.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Medical vs. Pharmacy Benefit Pathways
  3. Essential ICD-10 Codes and Documentation
  4. HCPCS J-Codes and NDC Information
  5. Step-by-Step Prior Authorization Process
  6. Common Denial Reasons and Solutions
  7. Appeals Process in Michigan
  8. Billing Verification and Audit Checklist
  9. Cost Assistance Programs
  10. FAQ

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all indications UnitedHealthcare Policy
Step Therapy Must try/fail conventional therapy or TNF inhibitors UnitedHealthcare Policy
Specialist Requirement Prescribed by relevant specialist UnitedHealthcare Policy
Combination Restrictions No concurrent targeted immunomodulators UnitedHealthcare Policy
Internal Appeal Deadline 180 days from denial Standard UHC policy
Michigan External Review 127 days after final internal denial Michigan DIFS

Medical vs. Pharmacy Benefit Pathways

Tremfya's coverage pathway depends on the formulation and administration setting:

Subcutaneous Injections (most common):

  • Typically covered under pharmacy benefit
  • Self-administered at home
  • Requires OptumRx prior authorization
  • NDC codes: 57894-0640-01, 57894-0640-06, 57894-0651-02

Intravenous Infusion (select indications):

  • Covered under medical benefit
  • Administered in clinical settings
  • Uses HCPCS J-code J1628
  • NDC: 57894-0650-02 (200-mg/20-mL vial)
Note: The benefit pathway affects your cost-sharing, prior authorization process, and appeal rights. Confirm with UnitedHealthcare which benefit applies to your specific prescription.

Essential ICD-10 Codes and Documentation

Primary Diagnosis Codes

Plaque Psoriasis:

  • L40.0 (Psoriasis vulgaris) - most specific for classic plaque psoriasis

Psoriatic Arthritis:

  • L40.50 (Arthropathic psoriasis, unspecified)
  • L40.51 (Distal interphalangeal psoriatic arthropathy)
  • L40.52 (Psoriatic arthritis mutilans)
  • L40.53 (Psoriatic spondylitis)
  • L40.54 (Psoriatic juvenile arthropathy)

Inflammatory Bowel Disease:

  • K50.x series for Crohn's disease (specify location)
  • K51.x series for ulcerative colitis (specify extent)

Critical Documentation Elements

For psoriasis and psoriatic arthritis, include:

  • Body Surface Area (BSA) percentage
  • Disease impact on daily function
  • Joint involvement (number, location, pattern)
  • Previous therapies and outcomes
  • Nail, scalp, or intertriginous involvement

For IBD indications, document:

  • Disease location and extent (endoscopy/imaging)
  • Activity indices (Mayo score, CDAI)
  • Complications (fistulas, strictures, bleeding)
  • Previous treatment failures
Tip: Use the most specific ICD-10 code available. Avoid unspecified codes like L40.9 when detailed documentation supports a more precise diagnosis.

HCPCS J-Codes and NDC Information

Billing Codes

HCPCS J-Code: J1628 (Injection, guselkumab, 1 mg)

  • Effective since January 1, 2019
  • One billable unit = 1 mg of medication

Required Modifiers for IV Administration:

  • JA - IV infusion administration
  • JZ - No product discarded from single-dose container

NDC Codes by Formulation

Formulation NDC Code Description
SC injection 57894-0640-01 100 mg/mL prefilled syringe
SC injection 57894-0640-06 100 mg/mL prefilled syringe (6-pack)
SC injection 57894-0651-02 100 mg/mL prefilled pen
IV infusion 57894-0650-02 200 mg/20 mL vial

Units Calculation

Common dosing for psoriasis/psoriatic arthritis:

  • 100 mg subcutaneously at weeks 0, 4, then every 8 weeks
  • Bill as 100 units per injection

IBD dosing varies by indication:

  • Induction and maintenance schedules differ
  • Verify exact dosing with FDA labeling

Step-by-Step Prior Authorization Process

Step 1: Gather Required Documentation

Patient responsibility:

  • Insurance card and member ID
  • Complete list of previous treatments
  • Current lab results if applicable

Provider responsibility:

  • Specialist consultation notes
  • Previous therapy documentation (drugs, dates, outcomes)
  • Diagnosis confirmation with ICD-10 codes

Step 2: Complete PA Request

Submit through OptumRx or UnitedHealthcare provider portal with:

  • Completed prior authorization form
  • Clinical notes supporting diagnosis
  • Documentation of step therapy compliance
  • Prescriber specialty verification

Step 3: Monitor Decision Timeline

  • Standard review: Up to 15 business days
  • Urgent requests: 72 hours with physician attestation
  • Check status via provider portal or phone

Step 4: If Approved

  • Verify authorization details (quantity, refills, duration)
  • Confirm pharmacy can fill prescription
  • Schedule patient follow-up for monitoring

Step 5: If Denied

  • Review denial letter for specific reasons
  • Gather additional documentation if needed
  • File internal appeal within 180 days

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing step therapy Document failed conventional/TNF therapy Drug names, dates, outcomes, intolerances
Insufficient severity Provide objective severity measures BSA, joint counts, activity scores
Wrong specialist Get referral to appropriate specialist Dermatology, rheumatology, or GI consultation
Combination therapy Discontinue other biologics Medication reconciliation, stop dates
Billing unit errors Verify NDC and units match dosing Correct NDC, accurate unit calculation
From our advocates: We've seen denials overturned when providers include specific details about why standard treatments failed - not just that they were tried, but the exact adverse effects or lack of response that made continuation impossible. This clinical narrative often makes the difference between approval and denial.

Appeals Process in Michigan

Internal Appeals (UnitedHealthcare)

First Level - Reconsideration:

  • File within 180 days of denial
  • Submit via provider portal or mail
  • Decision within 30 days (pre-service) or 60 days (post-service)

Second Level - Appeal:

  • Available if first level denied
  • Include additional clinical evidence
  • May request peer-to-peer review

External Review (Michigan DIFS)

Eligibility:

  • Must complete UnitedHealthcare's internal process
  • File within 127 days of final internal denial
  • Available for medical necessity disputes

How to File:

  1. Complete DIFS External Review Request form
  2. Include final denial letter and supporting documents
  3. Submit online, by mail, or fax to DIFS
  4. DIFS assigns Independent Review Organization (IRO)

Timelines:

  • Standard review: 60 days maximum
  • Expedited review: 72 hours (requires physician urgency letter)

Contact Information:

Important: Michigan's 127-day deadline is longer than the federal 120-day standard, giving you extra time to prepare your external review request.

Billing Verification and Audit Checklist

Pre-Submission Review

  • Correct NDC matches prescribed formulation
  • Units calculation aligns with actual dosing
  • ICD-10 codes are most specific available
  • Prior authorization number included
  • No concurrent biologic therapies billed
  • Prescriber specialty documented

Common Billing Errors to Avoid

  • Unit mismatches between claim and administration
  • Wrong NDC for subcutaneous vs. intravenous
  • Missing prior authorization reference number
  • Billing during manufacturer sample period
  • Combination therapy claims

Verification Resources

  • UnitedHealthcare provider portal for PA status
  • OptumRx formulary lookup tool
  • NDC verification through FDA Orange Book
  • HCPCS code verification through CMS

Cost Assistance Programs

Janssen CarePath Program:

  • Copay assistance for eligible patients
  • Maximum annual benefit varies by plan type
  • Cannot be used with government insurance
  • Apply at JanssenCarePath.com

Patient Assistance Program:

  • Free medication for qualifying uninsured patients
  • Income-based eligibility requirements
  • Requires physician enrollment

Foundation Grants:

  • Independent charitable foundations
  • Disease-specific assistance available
  • Income and insurance status requirements vary
Note: Inform your healthcare provider if you're using manufacturer assistance, as this may affect prior authorization requirements and billing procedures.

FAQ

How long does UnitedHealthcare prior authorization take for Tremfya in Michigan? Standard PA requests take up to 15 business days. Urgent requests with physician attestation are processed within 72 hours.

What if Tremfya isn't on my UnitedHealthcare formulary? Non-formulary medications may still be covered through the prior authorization process, but typically require stronger medical necessity documentation and step therapy compliance.

Can I request an expedited appeal in Michigan? Yes, both UnitedHealthcare (for urgent clinical situations) and Michigan DIFS (with physician urgency letter) offer expedited review processes.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your new provider has complete treatment records.

What happens if my appeal is denied by Michigan DIFS? You may pursue judicial review in Michigan state court within 60 days of the DIFS decision, though this requires legal representation.

How do I know if Tremfya is covered under medical or pharmacy benefits? Contact UnitedHealthcare member services with the specific NDC code. Subcutaneous formulations typically fall under pharmacy benefits, while IV infusions are usually medical benefits.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed rebuttals that address specific payer requirements. For medications like Tremfya, we identify the exact denial basis—whether it's step therapy, medical necessity, or quantity limits—and draft point-by-point appeals using the right clinical evidence and procedural requirements.

The system pulls appropriate citations from FDA labeling, peer-reviewed studies, and recognized guidelines, weaving them into appeals that meet UnitedHealthcare's specific criteria and Michigan's procedural requirements. This approach helps reduce the back-and-forth between providers and payers, getting patients access to needed treatments faster.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider for medical decisions. For assistance with insurance appeals in Michigan, contact DIFS at 877-999-6442.

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