TREMFYA™ Coding & Billing

TREMFYA™ Coding & Billing

This overview outlines the key points you need to know about reimbursement for TREMFYA™, including:

  • Coding for TREMFYA™
  • Reimbursement support

Coverage policies may vary by insurer or even between plans offered by the same insurer.

Patient insurance benefits investigation is provided by contracted service providers for Janssen CarePath, which is operated by Johnson & Johnson Health Care Systems Inc. on behalf of Janssen Pharmaceuticals, Inc. and Janssen Biotech, Inc. (Janssen). In this regard, Janssen CarePath assists healthcare providers 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 reimbursement support service has no independent value to providers apart from the product and is included within the cost of the product. While Janssen CarePath attempts to provide correct information, they make no representations or warranties, expressed or implied, as to the accuracy of the information. In no event shall Janssen CarePath, Janssen, or its employees or agents be liable for any damages resulting from or relating to the services. All providers and other users of this information agree that they accept responsibility for the use of this service. Importantly, insurance verification is the ultimate responsibility of the provider.

Third-party reimbursement is affected by many factors. The content provided is for informational purposes only and is not intended to provide reimbursement or legal advice and does not promise or guarantee coverage, levels of reimbursement, payment, or charge. Similarly, all CPT®* and HCPCS codes are supplied for informational purposes only and represent no promise or guarantee that these codes will be appropriate or that reimbursement will be made. 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. We strongly recommend that you consult with your payer organization(s) for local or actual coverage and reimbursement policies and with your internal reimbursement specialist for any reimbursement or billing questions.

*CPT® copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Coding

National Drug Code (NDC)

10-digit NDC for Ordering 11-digit NDC for Billing Description
57894-640-01 57894-0640-01 100 mg prefilled syringe
Single-dose 100 mg prefilled syringe of guselkumab for injection

HCPCS Codes

Site of Care Payer Claims following FDA approval up to the assignment of a permanent HCPCS code Permanent National Code
Physician Office Commercial J3590 - Unclassified biologics The permanent HCPCS code is anticipated to be issued for first use on January 1, 2019.
Medicare
HOPD Commercial J3590 - Unclassified drugs or biologicals
Medicare Immediately following FDA approval:
C9399*
Unclassified biologicals
Beginning 3-6 months after FDA approval:
Temporary, drug-specific
C code

*C9399 is reported under the Outpatient Prospective Payment System (OPPS) for new drugs and biologicals that are FDA approved but for which there is not yet an HCPCS code that describes the drug.

Please consult your local payer for specific coding policies or call Janssen CarePath for assistance at 877-CarePath (877-227-3728).

Reimbursement Support Through Janssen CarePath

Janssen CarePath provides information and assistance regarding coding, coverage, and claims process related to TREMFYA™. In addition, we can also investigate specialty pharmacy options that may be available to simplify product procurement and billing for healthcare providers. Finally, Janssen CarePath can provide reimbursement information and support directly to patients.

Janssen CarePath Care Coordinators are available to help answer your questions at 877-CarePath (877-227-3728), Monday-Friday, 8 AM - 8 PM ET.

Indication

TREMFYA™ is indicated for the treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

TREMFYA™ is administered as a 100 mg subcutaneous injection once every 8 weeks, after starter doses at weeks 0 and 4. TREMFYA™ is intended for use under the guidance and supervision of a physician. Patients may self-inject with TREMFYA™ after physician approval and proper training.

Important Safety Information For TREMFYA

Important Safety Information

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.

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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