By Counterforce Health Team in Tremfya (guselkumab) —

Work With Your Doctor to Get Tremfya (Guselkumab) Approved by UnitedHealthcare in New York: Complete PA Guide

Answer Box: Getting Tremfya Covered by UnitedHealthcare in New York

UnitedHealthcare requires prior authorization for Tremfya (guselkumab) and typically mandates step therapy with TNF inhibitors first. Success requires: (1) documented moderate-to-severe psoriasis with PASI/BSA scores, (2) proof of TNF inhibitor trial/failure or contraindication, and (3) negative TB screening within 12 months. If denied, New York's external appeal through the Department of Financial Services has overturned Tremfya denials—you have 4 months to file after final internal denial. Start today by scheduling a visit with your dermatologist to document disease severity and treatment history.

Table of Contents

  1. Set Your Goal: Understanding UnitedHealthcare's Requirements
  2. Visit Preparation: Building Your Clinical Case
  3. Evidence Kit: Labs, Guidelines, and Documentation
  4. Letter of Medical Necessity Structure
  5. Peer-to-Peer Review Support
  6. After-Visit Documentation Strategy
  7. Respectful Persistence and Escalation
  8. New York Appeals Process
  9. Cost Savings and Support Programs
  10. FAQ

Set Your Goal: Understanding UnitedHealthcare's Requirements

Getting Tremfya approved by UnitedHealthcare requires a collaborative approach with your dermatologist. The insurer's prior authorization policy mandates specific clinical documentation and often requires step therapy—meaning you'll need to try and fail other treatments first.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all plans UHC PA Policy
Step Therapy TNF inhibitor trial usually required Plan formulary documents
Age Requirement 18+ years FDA prescribing information
TB Screening Within 12 months of start Clinical documentation
Diagnosis Documentation PASI score, BSA percentage Provider assessment
Authorization Duration 12 months UHC policy

Your partnership with your dermatologist is crucial because they must provide the clinical evidence that meets UnitedHealthcare's medical necessity criteria. This isn't just about having psoriasis—it's about documenting the severity, previous treatment failures, and why Tremfya is the right next step.

Visit Preparation: Building Your Clinical Case

Before your appointment, prepare a comprehensive timeline that will help your doctor build the strongest possible case for Tremfya coverage.

Document Your Symptom History

Create a written timeline including:

  • Disease onset: When did your psoriasis symptoms first appear?
  • Severity progression: How has it worsened over time?
  • Affected areas: Which body parts are involved, especially sensitive areas like hands, face, or genitals?
  • Functional impact: How does psoriasis affect your work, relationships, or daily activities?
  • Quality of life: Sleep disruption, pain levels, emotional impact

Treatment History Documentation

Compile detailed records of:

  • Topical treatments tried: Corticosteroids, vitamin D analogs, calcineurin inhibitors
  • Systemic therapies: Methotrexate, cyclosporine, acitretin
  • Phototherapy: UVB, PUVA treatments and outcomes
  • Previous biologics: Especially TNF inhibitors like Humira, Enbrel, or Remicade
  • Reasons for discontinuation: Lack of efficacy, side effects, or contraindications
  • Duration of each treatment: How long you tried each therapy
Tip: Request medical records from previous dermatologists if you've switched providers. UnitedHealthcare needs documented proof of treatment failures, not just your verbal report.

Evidence Kit: Labs, Guidelines, and Documentation

Your dermatologist will need specific clinical evidence to support the prior authorization request. Help them gather this information efficiently.

Required Laboratory Work

TB Screening (Mandatory)

  • Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
  • Must be completed within 12 months of starting Tremfya
  • If positive, chest X-ray to rule out active disease
  • Document any previous TB treatment

Additional Labs to Consider

  • Hepatitis B panel (HBsAg, anti-HBc) due to reactivation risk
  • Complete blood count (baseline)
  • Liver function tests (baseline)

Clinical Assessment Requirements

Your dermatologist must document:

  • PASI Score: Psoriasis Area and Severity Index quantifying disease severity
  • Body Surface Area (BSA): Percentage of skin affected (≥10% for moderate-to-severe, or ≥3% with sensitive area involvement)
  • Physician Global Assessment: Overall disease severity rating
  • Photos: Clinical photography documenting affected areas (with your consent)

Supporting Guidelines and Literature

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by pulling the right clinical citations. Your dermatologist should reference:

  • American Academy of Dermatology psoriasis treatment guidelines
  • FDA prescribing information for Tremfya
  • Published studies on IL-23 inhibitor efficacy
  • Specialty guidelines supporting biologic use after conventional therapy failure

Letter of Medical Necessity Structure

A well-structured letter of medical necessity significantly improves approval chances. Work with your dermatologist to ensure their letter includes these key elements:

Essential Components

Patient Information Section

  • Full name, date of birth, insurance ID
  • Diagnosis with ICD-10 code (L40.0 for psoriasis vulgaris)
  • Prescribing dermatologist credentials and contact information

Clinical Documentation

  • Current PASI score and BSA percentage
  • Disease duration and progression
  • Impact on quality of life and functional status
  • Photographs or detailed descriptions of affected areas

Treatment History

  • Complete list of previous therapies with dates
  • Specific reasons for discontinuation or failure
  • Documentation of contraindications to preferred agents
  • Emphasis on TNF inhibitor trials if required by step therapy

Medical Necessity Rationale

  • Why Tremfya is appropriate for this patient
  • Expected clinical benefits
  • Risks of delaying treatment
  • References to supporting literature

Dosing and Administration

  • Tremfya 100 mg subcutaneously at weeks 0, 4, then every 8 weeks
  • Site of care (typically self-administered at home)
  • Monitoring plan
Clinician Corner: Include specific PASI and BSA measurements, not general statements like "severe psoriasis." UnitedHealthcare's reviewers look for quantifiable data that meets their threshold criteria.

Peer-to-Peer Review Support

If the initial prior authorization is denied, your dermatologist can request a peer-to-peer (P2P) review by calling UnitedHealthcare at 877-842-3210. This allows direct discussion with a clinical reviewer.

How You Can Support Your Doctor

Provide Availability Windows

  • Give your dermatologist several time slots when you're available for the P2P call
  • Be prepared to join the call if the reviewer has questions about your experience

Prepare a Concise Case Summary

  • One-page summary of your treatment history and current symptoms
  • Specific examples of how psoriasis affects your daily life
  • Clear timeline of previous therapy failures

Request Appropriate Reviewer

  • Ask your dermatologist to request a reviewer with dermatology expertise
  • Document if the reviewer lacks relevant specialty knowledge
Note: Studies show that only 16% of insurance P2P reviewers have appropriate specialty experience for the condition being reviewed. Don't hesitate to ask for a dermatologist reviewer.

After-Visit Documentation Strategy

After your appointment, maintain organized records to support the approval process and any potential appeals.

Documents to Save

  • Copy of the prior authorization request
  • Letter of medical necessity
  • Lab results (especially TB screening)
  • Clinical photos (if taken)
  • Treatment timeline summary
  • Insurance correspondence

Portal Communication

Use your healthcare provider's patient portal to:

  • Request copies of all submitted documentation
  • Ask for updates on PA status
  • Provide additional information if requested
  • Maintain a written record of all communications

Follow-Up Timeline

  • Week 1: Confirm PA submission with provider's office
  • Week 2: Check status via UnitedHealthcare member portal
  • Week 3: Contact provider if no decision received
  • After denial: Immediately request internal appeal

Respectful Persistence and Escalation

Insurance approvals often require multiple touchpoints. Maintain professional communication while advocating firmly for your care.

Effective Communication Strategies

With Your Provider's Office

  • Schedule regular check-ins rather than daily calls
  • Offer to help gather additional documentation
  • Express appreciation for their advocacy efforts
  • Ask specific questions: "What additional information does UnitedHealthcare need?"

With UnitedHealthcare

  • Reference your case number in all communications
  • Document names, dates, and reference numbers
  • Request written confirmation of verbal communications
  • Escalate to supervisors when appropriate

When to Escalate

Contact UnitedHealthcare member services immediately if:

  • PA decision exceeds standard timeframes (typically 15 business days)
  • You receive conflicting information from different representatives
  • Clinical urgency requires expedited review
  • Standard appeal process isn't progressing

New York Appeals Process

New York offers robust appeal rights that have successfully overturned Tremfya denials. The state's External Appeals Database shows Case Number 202109-141739 where a Tremfya denial for psoriasis was overturned.

Internal Appeals (First Step)

  • Timeline: File within 180 days of denial
  • Process: Submit through UnitedHealthcare member portal or mail
  • Required documents: Denial letter, additional clinical information, provider support
  • Decision timeline: 30 days for standard, 72 hours for urgent

External Appeals (New York DFS)

If internal appeals fail, New York's Department of Financial Services provides independent review:

  • Timeline: File within 4 months of final internal denial
  • Cost: Maximum $25 (waived for financial hardship or Medicaid)
  • Process: Independent medical experts review your case
  • Decision: Binding on UnitedHealthcare
  • Expedited review: 72 hours for urgent cases, 24 hours for drug denials with imminent health risk

Required Documentation for Appeals

  • Complete medical records
  • Provider letter supporting medical necessity
  • References to published medical literature
  • Documentation of treatment failures
  • Evidence of disease severity and functional impact

For free help with appeals in New York, contact Community Health Advocates at 888-614-5400.

Cost Savings and Support Programs

While working on insurance approval, explore financial assistance options to bridge coverage gaps.

Manufacturer Support

Janssen offers the Tremfya CarePath program with:

  • Copay assistance for commercially insured patients
  • Patient assistance programs for uninsured/underinsured
  • Reimbursement support and appeals assistance

Foundation Grants

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)
  • National Psoriasis Foundation assistance programs

State Programs

New York residents may qualify for:

  • Medicaid coverage (if income-eligible)
  • Essential Plan (for those above Medicaid limits)
  • State pharmaceutical assistance programs

FAQ

How long does UnitedHealthcare prior authorization take for Tremfya in New York? Standard PA decisions are typically made within 15 business days. Urgent requests may be expedited to 72 hours if clinical circumstances warrant.

What if Tremfya is non-formulary on my UnitedHealthcare plan? Non-formulary drugs can still be covered through medical exception requests. Your dermatologist must demonstrate medical necessity and that formulary alternatives are inappropriate.

Can I request an expedited appeal in New York? Yes, both UnitedHealthcare and New York DFS offer expedited appeals for urgent medical needs. Decisions are required within 72 hours (or 24 hours for drug denials with imminent health risk).

Does step therapy apply if I failed TNF inhibitors outside New York? Yes, documented treatment failures from any location count toward step therapy requirements, as long as medical records are available to verify the trials.

What happens if my dermatologist leaves the practice during my appeal? Request complete copies of your medical records immediately. A new provider can continue your appeal, but having comprehensive documentation prevents delays.

How much does Tremfya cost without insurance? List prices exceed $20,000 annually, but actual costs vary based on negotiated rates. Manufacturer assistance programs can significantly reduce out-of-pocket expenses for eligible patients.

Managing insurance approvals for specialty medications like Tremfya requires patience, organization, and strong provider collaboration. Counterforce Health helps patients and clinicians navigate these complex approval processes by creating targeted, evidence-backed appeals that align with each insurer's specific requirements.

Remember that New York's consumer-friendly appeal laws provide strong protections when insurance companies deny medically necessary treatments. With proper documentation and persistence, many patients successfully obtain Tremfya coverage even after initial denials.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For official information about insurance appeals in New York, visit the Department of Financial Services website.

Sources & Further Reading

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