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Guselkumab (Tremfya ®)
BCBS Tennessee·Dermatology, Rheumatology, Gastroenterology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
This is a NEW medical policy for Guselkumab (Tremfya®) that establishes coverage criteria, prior authorization requirements, and documentation standards for this biologic medication across four FDA-approved indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. The policy requires specialty-specific prescribers (dermatologist, rheumatologist, or gastroenterologist) and mandates TB screening prior to treatment initiation.
Action Required
By November 15, 2026: Billing team must configure prior authorization workflow in billing system to require approval for Guselkumab (Tremfya®) claims for all four indications. Update intake forms and templates to capture required documentation: (1) For plaque psoriasis—BSA affected, prior biologic/targeted synthetic therapy history, and clinical response; (2) For psoriatic arthritis—prior therapy attempts and clinical response; (3) For UC/CD—documentation of positive clinical response at continuation. Ensure system enforces prescriber specialty requirements (dermatology for psoriasis, rheumatology/dermatology for PsA, gastroenterology for UC/CD). Verify TB screening documentation is present before claim submission. Educate providers that authorization is limited to 12 months per approval cycle. Flag and deny any claims missing required clinical documentation or not meeting coverage criteria (e.g., patients under 6 years old, weighing less than 40 kg for applicable indications, or using concomitant biologics for the same indication). After December 1, 2026, do not process claims for this medication without prior authorization approval or they will be denied.