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HealthPartners

Coverage criteria policies

Guselkumab (Tremfya®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Guselkumab (Tremfya) requires prior authorization from HealthPartners Pharmacy Administration.

Coverage

Guselkumab (Tremfya) is generally covered subject to the indications listed below when all of the following criteria are met, and per member plan documents.

Initial Authorizations:

  1. Prescribed and followed by Dermatology; and,
  2. Prescribed for patients with Plaque Psoriasis; and,
  3. Requests for professional-administration will be reviewed on a case-by-case basis for medical necessity. In general, Tremfya should be self-administered unless patient has a limitation preventing self-administration; and,
  4. Patient has been diagnosed with severe psoriasis defined as at least 10% body surface area (BSA) or crucial body area involvement (palmar/plantar, scalp, or genitals), or pustular psoriasis; and,
  5. Patient has had a trial and failure (BSA involvement is not improved) of, or contraindications to, concurrent use of at least two of the regimens below for at least 12 weeks:
    1. Topical corticosteroid therapy
    2. Phototherapy: at least 20-30 treatments given 2-3 times weekly (HP will purchase home units – see the Home Phototherapy medical policy)
    3. Methotrexate 5mg-15mg weekly (GI intolerance requires trial of SC/IM methotrexate at 5mg-15mg weekly) in combination with folic acid supplementation
    4. Cyclosporine at a dose of at least 2.5 – 5 mg/kg/day until disease control achieved
    5. Acitretin at a dose of at least 25 mg daily; and,
  6. Patient has tried and failed all of the following preferred therapies for a duration of at least 12 weeks: Enbrel and Humira and Cosentyx and Otezla; and,
  7. No other biologic agent will be used concurrently to treat this indication; and,
  8. Tremfya is prescribed within the FDA-approved dosing regimen.

Initial authorization will be provided for one year.

Reauthorizations:

  1. The patient continues to meet the above initial authorization coverage criteria; and,
  2. Patient has been seen by provider within the past 14 months; and,
  3. Patient has been adherent to therapy; and,
  4. The medication continues to be effective, with provider attestation of one of the following:
    1. This patient has achieved low disease activity or remission; or,
    2. This patient has achieved sufficient disease control to continue this agent.

Re-authorizations will be provided for one year.

Definitions

TREMFYA is an interleukin-23 blocker indicated for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

HCPCS

Codes

Description

C9029

Injection, guselkumab, 1 mg (hospital outpatient use only – use before 1/1/2019)

J1628

Injection, guselkumab, 1 mg (effective 1/1/2019)

J3590

Unclassified biologics (use before 1/1/2019)

NDC Codes

Codes

Description

57894064001

Tremfya 100 MG/ML SOSY

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. TREMFYA package insert. Janssen Biotech, Inc. Horsham, PA 19044. October, 2017.

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Policy activity

  • 11/06/2017 - Date of origin
  • 01/01/2019 - Effective date
Review date
  • 11/2018

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