CommercialPrior AuthHigh impact
Guselkumab (Tremfya) (CPB 1011, reviewed 2026-06-29)
Aetna·Dermatology, Rheumatology, Gastroenterology·Medical Policy
Effective date
Jun 29, 2026
We identified it
Aug 15, 2026
Summary
Aetna has updated its Clinical Policy Bulletin 1011 for Guselkumab (Tremfya) effective immediately, establishing coverage criteria for plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. Key changes include: (1) Precertification is now REQUIRED for all intravenous guselkumab (Tremfya IV) through specialty pharmacy; (2) Strict prescriber specialty requirements are enforced (dermatologist for psoriasis, rheumatologist/dermatologist for PsA, gastroenterologist for IBD); (3) Initial approval requires prior biologic/targeted synthetic drug use OR specific clinical criteria including body surface area thresholds and documented treatment failures. Billing teams must implement precertification workflows immediately and ensure all claims include appropriate specialist documentation.
Action Required
IMMEDIATELY: (1) Billing and Prior Auth teams must establish precertification process for intravenous Tremfya (Tremfya IV) through Aetna specialty pharmacy—call (866) 752-7021 or fax (888) 267-3277 for all applicable plan designs. (2) Update billing system to flag ALL guselkumab claims requiring specialty provider verification: dermatologist for plaque psoriasis, rheumatologist or dermatologist for psoriatic arthritis, gastroenterologist for UC/Crohn's disease. (3) Create encounter form checklist requiring documentation of: prior biologic/targeted synthetic drug use, body surface area percentage affected, evidence of treatment failure (phototherapy, methotrexate, cyclosporine, acitretin), or clinical contraindications to standard therapies. (4) Providers must document clinical response metrics at each continuation visit: BSA reduction or symptom improvement for PsO; joint/dactylitis/enthesitis improvement for PsA; stool frequency/rectal bleeding/CRP/endoscopy findings for UC; abdominal pain/diarrhea/weight/hematocrit for CD. (5) Front-desk staff and prior auth team: Deny claims lacking required specialty provider signature or missing precertification for IV formulation. Claims without proper authorization will be denied.