By Counterforce Health Team in Tremfya (guselkumab) —

How to Get Tremfya (Guselkumab) Covered by UnitedHealthcare in New Jersey: Prior Authorization Guide and Appeal Process

Answer Box: Getting Tremfya Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Tremfya (guselkumab) with step therapy involving TNF inhibitors for psoriasis/psoriatic arthritis and documented biologic failure for IBD. Your fastest path to approval:

  1. Submit complete PA documentation including diagnosis codes, disease severity assessment, TB screening results, and detailed prior therapy history through the UnitedHealthcare provider portal
  2. Request medical exception if step therapy requirements don't fit your clinical situation, citing New Jersey's 2025 step therapy reform law (A1825) for expedited review
  3. If denied, file internal appeal within 180 days and prepare for external review through New Jersey's IHCAP program administered by Maximus Federal Services

Start today by gathering your insurance information and contacting your prescriber to initiate the prior authorization process.

Table of Contents

Why New Jersey State Rules Matter

New Jersey's insurance regulations create important protections that work alongside UnitedHealthcare's national policies. Understanding how these interact can significantly improve your chances of getting Tremfya covered.

Key New Jersey Advantages:

  • Step therapy reform (effective January 1, 2026) requires insurers to respond to medical exception requests within 24 hours for urgent cases, 72 hours for non-urgent
  • Robust external review system through IHCAP gives you an independent medical review after internal appeals
  • Continuity of care protections provide 90-day transition periods for ongoing specialty therapy

The rules vary by line of business. Commercial plans follow New Jersey's comprehensive regulations, while Medicare Advantage plans follow federal rules with some state overlay protections.

UnitedHealthcare Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all indications UnitedHealthcare provider portal 15 business days standard
Step Therapy TNF inhibitor trial for psoriasis/PsA; biologic failure for IBD UHC PA Medical Necessity form Must document failure/intolerance
Specialist Prescriber Dermatologist (psoriasis), rheumatologist (PsA), gastroenterologist (IBD) PA submission requirements Required for approval
TB Screening Documented negative test Clinical documentation Must be current
Disease Severity Objective assessment required Medical records Moderate-to-severe disease

Medical Necessity Criteria

UnitedHealthcare's medical necessity policy requires:

For All Indications:

  • Patient age ≥18 years
  • Documented tuberculosis screening with negative results
  • Prescription by appropriate specialist
  • No concurrent biologic therapy

For Psoriasis/Psoriatic Arthritis:

  • Moderate-to-severe disease documentation
  • Trial and failure of at least one TNF inhibitor (adalimumab, etanercept, certolizumab, golimumab) unless contraindicated

For IBD (Crohn's Disease/Ulcerative Colitis):

  • Documented inadequate response to conventional therapies
  • Prior biologic failure or contraindication
  • Disease activity scores (Modified Mayo Score ≥7 for UC)
Tip: Gather all prior therapy documentation before starting the PA process. UnitedHealthcare wants specific drug names, doses, duration of treatment, and reasons for discontinuation.

New Jersey Step Therapy Protections

New Jersey's Assembly Bill A1825, effective January 1, 2026, creates powerful protections for patients requiring specialty biologics like Tremfya.

Medical Exception Criteria

Your physician can request a step therapy exception if:

  • The required drug is contraindicated or likely to cause harm
  • The required drug is expected to be ineffective based on your clinical characteristics
  • You've already tried the step therapy medication and discontinued due to lack of efficacy or adverse events
  • The required drug would prevent you from fulfilling professional or physical activities
  • You're stable on current medication and switching would be disruptive

Expedited Review Timelines

Under New Jersey law, UnitedHealthcare must respond to step therapy exception requests:

  • 24 hours for urgent requests
  • 72 hours for non-urgent requests

This applies to Medicaid (NJ FamilyCare), State Health Benefits Program (SHBP), and School Employees' Health Benefits Program (SEHBP). Commercial plans may adopt similar timelines voluntarily.

Documentation Requirements

Include in your exception request:

  • Clinical justification explaining why step therapy is inappropriate
  • Prior medication history with specific outcomes
  • Supporting literature or guidelines when relevant
  • Specialist consultation notes

Continuity of Care During Coverage Transitions

If you're already on Tremfya and experience a coverage change, New Jersey provides important protections.

90-Day Transition Period

For patients with serious or complex conditions, you have the right to continued care with your current provider for 90 days after notification of a coverage change. This includes:

  • Ongoing specialty biologic therapy
  • Scheduled treatments and monitoring
  • Provider relationships for chronic conditions

How to Request Continuity of Care

  1. Notify your new insurer immediately upon receiving notice of coverage change
  2. Request formal written confirmation of continued access during transition
  3. Document all communications with both old and new insurers
  4. Work with your provider to submit continuity requests through established exception processes

Counterforce Health specializes in navigating these complex transition scenarios, helping patients maintain access to critical medications like Tremfya during insurance changes by drafting targeted appeals that align with both federal and state requirements.

Appeals Process: Internal and External Review

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial date to file

Required Documentation:

  • Copy of denial letter
  • Medical records supporting medical necessity
  • Specialist letters addressing denial reasons
  • Updated clinical information if available

Submission Methods:

  • UnitedHealthcare member portal
  • Mail to address on denial letter
  • Fax (verify current number with customer service)

External Review Through IHCAP

New Jersey's Independent Health Care Appeals Program, administered by Maximus Federal Services, provides independent medical review.

Eligibility:

  • Must complete UnitedHealthcare's internal appeals process first
  • Submit within 60 days of final denial
  • $25 filing fee (waived for Medicaid/NJ FamilyCare)

Timeline:

  • 5 business days for preliminary review
  • 45 calendar days for standard decision
  • 48 hours for expedited review (urgent cases)

Required Forms:

  • External Appeal Application Form
  • Copy of final denial letter
  • Supporting medical documentation
  • Appeal summary explaining why additional review is needed
From Our Advocates: We've seen cases where patients successfully overturned UnitedHealthcare denials by emphasizing disease progression during appeal delays. One composite case involved a patient with moderate-to-severe psoriasis who documented worsening symptoms during the internal appeal process, leading to expedited external review approval. While outcomes vary, thorough documentation of clinical urgency often strengthens appeals.

Practical Scripts and Documentation

Patient Phone Script for UnitedHealthcare

"Hello, I'm calling about prior authorization for Tremfya, generic name guselkumab, for [your condition]. My member ID is [number]. Can you tell me the current status of my PA request submitted on [date]? If it was denied, I'd like to understand the specific reasons and start the internal appeal process. Can you also confirm the deadline for filing an appeal and provide the correct submission address or portal?"

Medical Necessity Letter Checklist for Providers

Your specialist should include:

  • Diagnosis with ICD-10 codes (L40.0 for plaque psoriasis, L40.5x for psoriatic arthritis)
  • Disease severity assessment with objective measures
  • Prior therapy history including specific TNF inhibitors tried, doses, duration, and outcomes
  • Clinical rationale for Tremfya based on mechanism of action and patient factors
  • Contraindications to step therapy requirements if applicable
  • Treatment goals and monitoring plan
  • Supporting literature from FDA labeling or specialty guidelines

Appeal Letter Template

When appealing a denial, address each specific reason mentioned in the denial letter:

"This appeal addresses the denial of Tremfya (guselkumab) dated [date] for [patient name], member ID [number]. The denial cited [specific reason]. However, [clinical justification addressing that reason]. Per New Jersey insurance regulations, this medication is medically necessary because [cite specific criteria from UnitedHealthcare's own policy]. Attached documentation includes [list all supporting materials]."

Understanding Plan Limitations

ERISA and Self-Funded Plan Differences

If your UnitedHealthcare plan is provided through a large employer, it may be self-funded and governed by federal ERISA law rather than New Jersey state regulations. This means:

  • New Jersey's step therapy protections may not apply
  • External review follows federal rather than state processes
  • Appeal deadlines and procedures may differ

How to Check: Look for "self-funded" or "self-insured" on your benefits summary, or call member services to confirm.

Medicare Advantage Considerations

UnitedHealthcare Medicare Advantage plans follow federal Medicare rules:

  • Prior authorization timelines follow CMS standards
  • Appeals go through Medicare's process, not New Jersey IHCAP
  • Step therapy protections are limited to federal requirements

Quick Reference Guide

Important Contacts

  • UnitedHealthcare Member Services: Number on your insurance card
  • New Jersey DOBI Consumer Hotline: 1-800-446-7467
  • IHCAP Specific Questions: 1-888-393-1062
  • Maximus IHCAP Portal: njihcap.maximus.com

Key Deadlines

  • Internal Appeal: 180 days from denial
  • External Appeal: 60 days from final internal denial
  • Step Therapy Exception Response: 24-72 hours (New Jersey law, effective 2026)
  • Continuity of Care: Request within 90 days of coverage change notification

Essential Documents to Gather

  • Insurance card and member ID
  • Denial letters and EOBs
  • Complete medical records for your condition
  • Documentation of all prior therapies tried
  • Specialist consultation notes
  • Current lab results and imaging
  • Prescription history from pharmacy

Frequently Asked Questions

Q: How long does UnitedHealthcare prior authorization take for Tremfya in New Jersey? A: Standard review takes up to 15 business days. Urgent requests may be processed within 72 hours if clinical urgency is documented.

Q: What if Tremfya is non-formulary on my UnitedHealthcare plan? A: You can request a formulary exception through the same prior authorization process. Provide documentation that formulary alternatives are inappropriate for your condition.

Q: Can I request an expedited appeal in New Jersey? A: Yes, both UnitedHealthcare internal appeals and IHCAP external reviews offer expedited processing for urgent medical situations.

Q: Does step therapy apply if I failed TNF inhibitors outside of New Jersey? A: Yes, prior therapy failures from other states count toward step therapy requirements. Provide complete documentation from your previous providers.

Q: What happens if I'm denied by both internal appeal and external review? A: You may have additional options including filing complaints with New Jersey DOBI, seeking legal counsel, or exploring manufacturer patient assistance programs.

Q: How much does Tremfya cost without insurance coverage? A: List prices exceed $20,000 annually. Explore Janssen CarePath patient assistance, foundation grants, and state pharmaceutical assistance programs if coverage is denied.

Q: Can my doctor prescribe a different IL-23 inhibitor if Tremfya is denied? A: Alternative IL-23 inhibitors like Skyrizi may have different coverage criteria. Your doctor can evaluate whether switching medications or continuing the appeal process is more appropriate.

Q: What documentation helps most in Tremfya appeals? A: Disease activity scores, photographs (for psoriasis), quality of life assessments, and detailed documentation of prior therapy failures with specific reasons for discontinuation strengthen appeals significantly.

When facing coverage challenges with specialty medications like Tremfya, Counterforce Health helps patients and providers navigate the complex prior authorization and appeals process by creating evidence-backed submissions tailored to each insurer's specific requirements and state regulations.

Sources & Further Reading

This guide provides educational information and should not replace professional medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. For personalized guidance, consult with your healthcare provider and insurance representative. Information current as of late 2025.

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