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Tremfya (guselkumab) (New)
Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 15, 2026
Summary
Humana Medicare Advantage is implementing a new prior authorization policy for Tremfya (guselkumab) effective January 1, 2027. The policy covers four indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease across multiple formulations (IV and subcutaneous). Billing teams must verify member eligibility against specific clinical criteria (diagnosis, age, weight, prior treatment) before claims submission.
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What to do
by Jan 1, 2027 · 9 steps
01Billing team must implement prior authorization requirements for all Tremfya (guselkumab) claims on Humana Medicare Advantage plans.
02Before submitting claims, verify that members meet ALL applicable criteria based on indication.
03Plaque Psoriasis: diagnosis of moderate-to-severe plaque psoriasis, age ≥6 years, weight ≥40 kg, prior trial of conventional oral systemic treatment (methotrexate, cyclosporine) or contraindication to such therapy.
04Psoriatic Arthritis: diagnosis of active psoriatic arthritis, age ≥6 years, weight ≥40 kg.
05Ulcerative Colitis: diagnosis of moderate-to-severely active ulcerative colitis, age ≥18 years.
06Crohn's Disease: diagnosis of moderately-to-severely active Crohn's disease, age ≥18 years.
07Update billing software and prior authorization submission workflows to capture these criteria.
08Route all Tremfya requests through Humana's preauthorization process before claim submission.
09Obtain prior authorization approval before dispensing or administering; claims submitted without prior authorization will be denied.
Original notice
Tremfya (guselkumab) (New)
mcp.humana.com · Always check the source before changing claims.