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 Letter of Medical Necessity template 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.

Letter of Exception

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 Letter of Exception template you can use to create your own letter to request an exception for TREMFYA^®.

Letter of Appeal

Below is a Letter of Appeal template:

Prior Authorization

A standardized, or "uniform," prior authorization (PA) form may be required in certain states to submit PA requests to a health plan for review, along with the necessary clinical documentation. These standard forms can be used across payers and health benefit managers.

Standardized PA Forms are only applicable to prescription drug benefits; they are not applicable to medical services or procedures.
Standardized PA Forms are typically not applicable to self-funded employer-sponsored health plans, Medicare Part D plans, and Medicaid fee-for-service plans.

Please visit the Know Your State Interactive Tool to learn what is required for your state.

Additional information on the PA process at major payers is shown below. Please see table below, use the Janssen CarePath Provider Portal, or contact Janssen CarePath at 877-CarePath (877-227-3728) for assistance in obtaining PA 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.

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 Prior Authorization California Prescription Prior Authorization California Prescription Drug Prior Authorization Request Form Georgia Prescription Prior Authorization
Blue Cross and Blue Shield of Alabama	Prescription Coverage Guidelines (Search by product name) Provider-Administered Drug Policies and Forms General Prescription Drug Coverage Authorization Request Form
Blue Cross and Blue Shield of Florida/Florida Blue	Prior Authorization Program Information (Search by product name) Medical Pharmacy Prior Authorization Lists and Utilization Management Physician and Provider Forms
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 by product name) 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 Prior Authorization Process for Provider-Administered Specialty Medications
BlueCross BlueShield of Texas	Prior Authorization and Step Therapy Programs: Request Forms Prior Authorization Criteria and Forms for Drugs 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	Provider Resources Pharmacy Resources: Prior Authorization Forms Medication Prior Authorization Form
CVS Caremark	Electronic 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 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 Specialty Drugs Pharmacy Prior Authorizations Online Pharmacy Prior Authorization Portal (Members)
Independence Blue Cross	Prior Authorization: Pharmacy Benefit Specialty Medical Benefit Drugs (Search by product name) 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

Patient insurance benefits investigation and other Janssen CarePath program offerings are provided by third-party service providers for Janssen CarePath, under contract with Johnson & Johnson Health Care Systems Inc., on behalf of Janssen Pharmaceuticals, Inc., Janssen Biotech, Inc., and Janssen Products, LP (Janssen). Janssen CarePath is not available to patients participating in the Patient Assistance Program offered by Johnson & Johnson Patient Assistance Foundation. The availability of information and assistance may vary based on the Janssen medication, geography and other program differences. Janssen CarePath assists healthcare providers (HCPs) in the determination of whether treatment could be covered by the applicable third-party payer based on coverage guidelines provided by the payer, and patient information provided by the healthcare provider under appropriate authorization following the provider's exclusive determination of medical necessity. This information and assistance are made available as a convenience to patients, and there is no requirement that patients or HCPs use any Janssen product in exchange for this information or assistance. Janssen assumes no responsibility for and does not guarantee the quality, scope, or availability of the information and assistance provided. The third-party service providers, not Janssen, are responsible for the information and assistance provided under this program. Each HCP and patient is responsible for verifying and confirming any information provided. All claims and other submissions to payers should be in compliance with all applicable requirements.

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Last updated on September 4, 2020.

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Prior Authorization, Exceptions, & Appeals

Prior Authorization, Exceptions, & Appeals

Letter of Medical Necessity

Letter of Exception

Letter of Appeal

Prior Authorization