By Counterforce Health Team in Tremfya (guselkumab) —

Renewing Tremfya (Guselkumab) Coverage with Humana in New York: 2025 Requirements and Timeline

Answer Box: To renew Tremfya (guselkumab) coverage with Humana in New York, submit your renewal request with updated clinical documentation 30-60 days before your current authorization expires. Include PASI scores showing continued response, adherence documentation, and any new clinical notes. Humana reviews renewals within 72 hours (standard) or 24 hours (expedited). If denied, you have internal appeal rights plus New York's external appeal process through the Department of Financial Services within 4 months of final denial.

Table of Contents

When to Start Your Renewal Process

Your Tremfya (guselkumab) renewal process should begin 30-60 days before your current authorization expires. Here are the key triggers to watch for:

Early Warning Signs

  • Authorization expiration date approaching (check your most recent approval letter)
  • Pharmacy notification about upcoming coverage gaps
  • Changes to your Humana plan (new formulary year, plan switch)
  • Clinical status changes that might affect approval
Tip: Set a calendar reminder 60 days before your expiration date. Humana's renewal reviews take up to 72 hours, but gathering documentation can take weeks.

High-Priority Renewal Situations

Start your renewal process immediately if you:

  • Have had any treatment interruptions or adherence issues
  • Changed prescribers or care teams
  • Experienced new side effects or safety concerns
  • Need to switch from subcutaneous to different formulations

Required Documentation for Renewal

Humana requires comprehensive clinical documentation to demonstrate continued medical necessity for Tremfya renewal. Here's what you'll need:

Core Clinical Evidence

PASI Score Documentation

  • Current PASI score (ideally ≤3 for maintenance therapy)
  • Percentage improvement from baseline (PASI 90 or PASI 100 preferred)
  • Assessment timeline showing scores at weeks 12, 16, 28, and current

Treatment Response Evidence

  • Clinical notes documenting sustained benefit
  • Photographs or objective skin assessments (if available)
  • Quality of life improvements or functional status changes

Required Medical History

Prior Therapy Documentation

  • Complete list of previous treatments tried and failed
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Duration of each prior therapy attempt

Current Clinical Status

  • Confirmation of ongoing moderate-to-severe plaque psoriasis diagnosis
  • ICD-10 codes (L40.0 for plaque psoriasis, L40.50-L40.59 for psoriatic arthritis)
  • Comorbidity documentation if relevant

Safety and Monitoring Records

  • Tuberculosis screening results (chest X-ray, QuantiFERON-Gold)
  • Complete blood count and liver function tests
  • Documentation of any infections or adverse events
  • Vaccination status (avoid live vaccines during therapy)
Clinician Corner: Your medical necessity letter should address: (1) current disease severity with objective measures, (2) documented response to Tremfya therapy, (3) lack of adequate alternatives, and (4) continued monitoring plan. Reference FDA prescribing information for approved indications and dosing.

Submission Timeline and Process

Standard Renewal Timeline

Timeline Action Required Who Does It
60 days before expiration Begin gathering documentation Patient/Provider
45 days before expiration Complete clinical assessments Provider
30 days before expiration Submit renewal request Provider
Within 72 hours Humana review decision Humana
If approved Continue therapy Patient
If denied Begin appeal process Patient/Provider

How to Submit Your Renewal

Provider Portal Method

  1. Log into the Humana provider portal
  2. Navigate to "Prior Authorization Search Tool"
  3. Complete the Tremfya renewal form with updated clinical data
  4. Upload all supporting documentation
  5. Submit and save confirmation number

Alternative Submission Methods

  • Fax: Use Humana's prior authorization fax line (verify current number through provider portal)
  • Phone: Call Humana provider services for urgent renewals
  • Mail: Send to address specified in your original approval letter
Note: Humana processes renewal requests within 72 hours for standard reviews or 24 hours for expedited reviews when medical urgency is documented.

If Your Coverage Lapses

If your Tremfya authorization expires before renewal approval, you have several options to maintain treatment continuity:

Immediate Bridge Options

Temporary Coverage Requests

  • Request expedited review citing medical necessity
  • Submit "urgent" designation if interruption poses health risks
  • Use Humana's 24-hour expedited timeline for urgent cases

Clinical Bridge Therapy While waiting for renewal approval, discuss these temporary options with your prescriber:

  • High-potency topical corticosteroids for localized flares
  • Systemic corticosteroids for severe widespread flares (short-term use only)
  • Phototherapy if available and appropriate
Important: Do not stop Tremfya abruptly without medical supervision. Loss of disease control can occur within 4 weeks of discontinuation.

Financial Bridge Options

Manufacturer Support

  • Janssen CarePath offers copay assistance
  • Patient assistance programs for uninsured or underinsured patients
  • Bridge programs during insurance transitions

Pharmacy Options

  • Discuss temporary fill options with your specialty pharmacy
  • Ask about manufacturer samples through your prescriber
  • Consider split-fill prescriptions to extend coverage

Annual Formulary Changes

Each year, Humana may modify its formulary, affecting your Tremfya coverage. Here's what to monitor:

2025 Formulary Status

Tremfya remains on Humana's 2025 formulary as a Tier 5 (specialty) medication, requiring prior authorization and likely step therapy for new patients.

Changes to Watch For

Coverage Modifications

  • Tier placement changes (affecting copays)
  • New step therapy requirements
  • Quantity limit adjustments
  • Site-of-care restrictions

Required Actions

  • Review your Annual Notice of Change (ANOC) carefully
  • Compare formulary changes during open enrollment
  • Contact Humana if you receive 30-day advance notice of coverage changes
Tip: Humana must provide 30-day advance notice before removing a drug from formulary or changing coverage terms for existing users.

Appeals Process in New York

If Humana denies your Tremfya renewal, New York residents have robust appeal rights:

Internal Appeals with Humana

Step 1: Standard Internal Appeal

  • File within 60 days of denial notice
  • Submit via Humana member portal or phone
  • Include all supporting clinical documentation
  • Expect decision within 30 days (standard) or 72 hours (expedited)

New York External Appeals

Step 2: Department of Financial Services External Review If Humana upholds its denial, you can file an external appeal with New York's Department of Financial Services:

Eligibility Requirements

  • Must complete Humana's internal appeal first
  • Denial must be for "medical necessity" or "experimental/investigational" reasons
  • File within 4 months of final adverse determination

How to File

  1. Download the External Appeal Application
  2. Include Humana's final denial letter
  3. Attach all medical records and prescriber documentation
  4. Submit with $25 filing fee (waived for Medicaid or financial hardship)

Timeline and Decision

  • Standard external appeals: decided within 30 days
  • Expedited appeals: 72 hours (24 hours for urgent drug denials)
  • Decision is binding on Humana
  • Filing fee refunded if you win

Consumer Assistance

Community Health Advocates Call 888-614-5400 for free help with appeals and understanding your rights in New York.

DFS Consumer Hotline Call 800-400-8882 or email [email protected] for external appeal questions.

Personal Renewal Tracker

Use this checklist to stay organized throughout your renewal process:

60 Days Before Expiration

  • Review current authorization expiration date
  • Schedule appointment for clinical assessment
  • Request medical records from all providers
  • Verify current Humana formulary status

45 Days Before Expiration

  • Complete PASI score assessment
  • Update laboratory tests (CBC, LFTs)
  • Document treatment response and adherence
  • Obtain prescriber letter of medical necessity

30 Days Before Expiration

  • Submit complete renewal packet to Humana
  • Save confirmation number and submission date
  • Set follow-up reminder for 72-hour decision timeline
  • Prepare appeal documentation (just in case)

After Submission

  • Track application status via Humana portal
  • Follow up if no decision within stated timeline
  • If approved: update pharmacy and schedule next renewal
  • If denied: immediately begin appeal process

At Counterforce Health, we help patients and providers navigate complex prior authorization renewals by turning insurance requirements into targeted, evidence-backed submissions. Our platform analyzes payer policies and creates comprehensive renewal packets that address specific insurer criteria, improving approval rates and reducing administrative burden.

FAQ

How long does Humana take to review Tremfya renewals in New York? Humana reviews renewal requests within 72 hours for standard cases or 24 hours for expedited reviews when medical urgency is documented.

What if my PASI score has increased since starting Tremfya? Document the reasons for any score changes (medication adherence, comorbid conditions, stress factors) and emphasize overall improvement from baseline. Include prescriber assessment of continued benefit.

Can I request an expedited renewal review? Yes, if treatment interruption would pose serious health risks. Your prescriber must document medical urgency and potential harm from delayed therapy.

Does Humana require step therapy for Tremfya renewals? For renewals, step therapy typically doesn't apply if you're already established on therapy. However, document your prior treatment failures in case of any coverage questions.

What happens if Humana removes Tremfya from formulary mid-year? Humana must provide 30-day advance notice and may offer transition coverage or formulary exceptions. You can appeal non-formulary status through the standard appeals process.

How do I get help with my renewal if I can't afford assistance? Contact Community Health Advocates at 888-614-5400 for free assistance with renewals and appeals in New York. Counterforce Health also helps patients and providers create stronger prior authorization submissions.

Can I switch to a different IL-23 inhibitor if Tremfya is denied? Yes, but you'll need a new prior authorization for any alternative biologic. Your prescriber should document why Tremfya specifically is preferred over formulary alternatives.

What if I moved to New York from another state during treatment? Provide documentation of your treatment history and response from your previous state. Humana should honor established therapy, but may require updated clinical assessments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance plan for personalized guidance. For official appeals and coverage information, contact Humana directly or consult New York State Department of Financial Services resources.

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