Tremfya - Insurance Coverage - Prior Authorization, Exceptions, & Appeals

Prior Authorization, Exceptions, & Appeals

There are 3 primary categories of requests:

Prior authorizations

Coverage determinations (including exception requests)

Appeals

Click here for a brochure that has been developed to help healthcare providers understand the information that payers may require for coverage of medically necessary drug therapies.

Janssen Link provides Janssen subcutaneous products to eligible patients whose commercial insurance delays (>5 business days) or denies treatment. Click here for more information.

Letter of Medical Necessity

Below is a sample Letter of Medical Necessity that you can use to create your letter documenting the medical necessity for treatment with TREMFYA^® for your patient. You may submit the letter to the payer either with the initial claim or when requesting reconsideration of a denied claim.

Exception Letter

An exception request is a specific type of coverage determination that asks a payer to reconsider an adverse tiering or formulary decision. Below is a sample letter you can use to create your own letter to request an exception for TREMFYA^®.

Below is a sample Letter of Appeal:

Prior Authorization

Some health plans in select states must use their state's uniform prior authorization request form. Click here to see if your state is included.

Uniform Prior Authorization Information for Select States

Other payers follow a different process. Please see table below or contact Janssen CarePath at 877-CarePath (877-227-3728) for assistance in obtaining prior authorization forms.

The information provided is not a guarantee of coverage or payment (partial or full). Actual benefits are determined by each plan administrator in accordance with its respective policy and procedures. This document is presented for informational purposes only and is not intended to provide reimbursement or legal advice, nor does it promise or guarantee coverage, levels of reimbursement, payment, or charge. It is not intended to increase or maximize reimbursement by any payer. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current as of the issue date of this document, the information may not be as current or comprehensive when you view it. Please refer to the applicable plan's website, or contact the plan for more information about coverage or any restrictions or prerequisites that may apply. We strongly recommend you consult the payer organization for its reimbursement policies.

Janssen CarePath does not endorse and is not responsible for the content on any of the websites listed below, or the services provided by these organizations. Clicking on any of the links below will take you to a website to which our Privacy Policy does not apply. We encourage you to read the privacy policy of every website you visit.

Click on the payer link to be taken to the payer's website.

Payer	Prior Authorization Information
Aetna	Formularies & Pharmacy Clinical Policy Bulletins Provider Precertification Lists Health Care Professional Forms: Specialty Pharmacy Medication Request Prior Authorization Form
Anthem Blue Cross Blue Shield	Prescription Drug Prior Authorization Information California Prescription Drug Prior Authorization Information California Prescription Drug Prior Authorization Request Form Georgia Prescription Drug Prior Authorization Information
Blue Cross and Blue Shield of Alabama	Pharmacy: Drug Coverage Guidelines (Search by drug name) Provider-Administered Drug Policies and Forms (Acceptance required to view) General Prescription Drug Coverage Authorization Request Form
Blue Cross and Blue Shield of Florida/Florida Blue	Prior Authorization Program Information Medical Pharmacy Prior Authorization Lists and Utilization Management Member Prescription Drug Prior Authorization Forms Specialty Pharmacy Request Form
Blue Cross and Blue Shield of Illinois	Prior Authorization and Step Therapy Programs Specialty Drug Request Form Prior Authorization Request Form
Blue Cross Blue Shield of Massachusetts	Prior Authorization - Pharmacy Online Prior Authorization Requests
Blue Cross Blue Shield of Michigan	Provider Prior Authorization for Medical Drugs Prior Authorization and Step Therapy Coverage Criteria Medication Prior Authorization Request
Blue Cross and Blue Shield of Minnesota	Prescription Drugs (Search drug list for medication requirements) Pharmacy Utilization Management Tools & Resources For Health Care Providers: Electronic Prior-Authorization
Blue Cross and Blue Shield of Montana	Prior Authorization and Step Therapy Programs Provider Forms and Documents Prior Authorization Request Form Online Prior Authorization Form
Blue Cross and Blue Shield of New Mexico	Prior Authorization and Step Therapy Programs Prior Authorization Forms (Select pharmacy tab) Prior Authorization Request Form Online Prior Authorization Form
Blue Cross and Blue Shield of North Carolina	Prior Review and Limitations Prior Authorization Facsimile Form Online Prior Authorization Requests
Blue Cross and Blue Shield of Oklahoma	Prior Authorization and Step Therapy Programs: Request Forms Prior Authorization Request Form Online Prior Authorization Form
BlueCross BlueShield of Tennessee	Pharmacy Resources & Forms Specialty Medications Program Prior Authorization Process for Provider-Administered Specialty Medications
BlueCross BlueShield of Texas	Prior Authorization and Step Therapy Programs: Request Forms Physician-Administered Drug Policies and Forms Prior Authorization Request Form Online Prior Authorization Form
CareFirst BlueCross BlueShield	Pharmacy Forms Pharmacy Prior Authorization Prior Authorization Inquiries and Appeals Online Prior Authorization Form
Cigna	Pharmacy Resources Pharmacy Prior Authorization Forms (Select drug) Medication Prior Authorization Form
CVS Caremark	Prior Authorization Information Clinical Prior Authorization Criteria Request Form Prior Authorization for Professionally Administered Drugs
EmblemHealth	Pharmacy Resources and Forms Injectables and Specialty Pharmacy Program and Form Prior Authorizations/Coverage Determinations
Harvard Pilgrim Health Care, Inc.	Medication Prior Authorization Program Medication Request Forms and Clinical Coverage Criteria Medical Drugs Prior Authorization Massachusetts Standard Form for Medication Prior Authorization Requests
Health Net	Pharmacy and Prior Authorization Forms Prior Authorization Forms for Specific Drugs
Highmark Blue Cross Blue Shield	Prescription Drug Medication Request Form Provider Resources for Prior Authorization Submissions
Horizon Blue Cross Blue Shield of New Jersey	Pharmacy Guidelines Prior Authorization/Medical Necessity Determination Medicine List Online Prior Authorization Form Prior Authorization/Medical Necessity Determination Fax Form
Humana	Medical and Pharmacy Coverage Policies Prescribing: Prior Authorization for Pharmacy Drugs Pharmacy Prior Authorizations Online Pharmacy Prior Authorization Portal (Members) Medical Precertification Request Form
Independence Blue Cross	Prior Authorization: Pharmacy Benefit Specialty Medical Benefit Drugs (search for product) Prior Authorization Forms
Kaiser Permanente (Kaiser Foundation Health Plan, Inc.) Kaiser Permanente Washington	Formulary and Formulary Exceptions Form (Select Region) Injectable Drugs Requiring Prior Authorization (WA members) Non-Medicare Injectable Drugs Requiring Prior Authorization List (WA members)
Premera Blue Cross	Drugs Requiring Approval Pharmacy Services Prior Authorization Request Form
Wellmark Blue Cross and Blue Shield	Provider Drug Information Provider Prior Authorization

Important Safety Information

CONTRAINDICATIONS
TREMFYA^® is contraindicated in patients with a history of serious hypersensitivity reaction to guselkumab or to any of the excipients.

WARNINGS AND PRECAUTIONS
Infections
TREMFYA^® may increase the risk of infection. Treatment with TREMFYA^® should not be initiated in patients with a clinically important active infection until the infection resolves or is adequately treated.

Consider the risks and benefits of treatment prior to prescribing TREMFYA^® in patients with a chronic infection or a history of recurrent infection. Instruct patients receiving TREMFYA^® to seek medical help if signs or symptoms of clinically important chronic or acute infection occur. If a patient develops a clinically important or serious infection, or is not responding to standard therapy, closely monitor and discontinue TREMFYA^® until the infection resolves.

Pre-Treatment Evaluation for Tuberculosis (TB)
Evaluate patients for TB infection prior to initiating treatment with TREMFYA^®. Initiate treatment of latent TB prior to administering TREMFYA^®. Monitor patients for signs and symptoms of active TB during and after TREMFYA^® treatment. Do not administer TREMFYA^® to patients with active TB infection.

Hypersensitivity Reactions
Serious hypersensitivity reactions have been reported with postmarket use of TREMFYA^®, some cases required hospitalization. If a serious hypersensitivity reaction occurs, discontinue TREMFYA^® and initiate appropriate therapy.

Immunizations
Prior to initiating TREMFYA^®, consider completion of all age-appropriate immunizations according to current immunization guidelines. Avoid use of live vaccines in patients treated with TREMFYA^®.

ADVERSE REACTIONS
Most common (≥1%) adverse reactions associated with TREMFYA^® include upper respiratory infections, headache, injection site reactions, arthralgia, diarrhea, gastroenteritis, tinea infections, and herpes simplex infections.

Please read the full Prescribing Information and Medication Guide for TREMFYA^®. Provide the Medication Guide to your patients and encourage discussion.

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Janssen CarePath

Savings Program

Janssen CarePath Provider Portal

Prior Authorization, Exceptions, & Appeals

Prior Authorization, Exceptions, & Appeals

Letter of Medical Necessity

Exception Letter

Prior Authorization

Important Safety Information