Medicare AdvantagePrior AuthMedium impact
Tremfya (guselkumab) (Revised)
Humana·Dermatology, Rheumatology, Gastroenterology·Medicare Advantage
Effective date
Jan 1, 2025
We identified it
Jul 23, 2026
Summary
Humana has issued a revised Medicare Advantage prior authorization policy for Tremfya (guselkumab) effective January 1, 2025, covering four indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. The policy requires prior authorization for all formulations (IV and subcutaneous) with specific clinical criteria based on diagnosis, age, weight, and prior treatment history. Billing teams must ensure all Tremfya claims include appropriate prior authorization before submission to avoid denials.
Action Required
By December 31, 2024: Billing team must implement prior authorization requirement in billing system for all Tremfya (guselkumab) formulations under Medicare Advantage plans. Create authorization submission checklist requiring: (1) diagnosis confirmation (plaque psoriasis, psoriatic arthritis, ulcerative colitis, or Crohn's disease), (2) age verification (6+ years for psoriasis/arthritis; 18+ for GI conditions), (3) weight documentation (40+ kg for psoriasis/arthritis), (4) prior treatment documentation (conventional oral systemic therapy trial or contraindication for psoriasis/arthritis). Train clinical staff to gather required clinical information before submission. Update encounter templates to capture these criteria. All Tremfya claims submitted without prior authorization will be denied by Humana. Verify current policy version at www.humana.com/PAL before processing claims.