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Colorado Rocky Mountain HP Tremfya Prior Auth | OpenPayer

CurrentColorado Rocky Mountain Health PlansPolicy N/A

Tremfya (guselkumab) — Prior Authorization and Reauthorization Criteria

Prior authorization and reauthorization criteria for subcutaneous Tremfya (guselkumab) for plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease for Colorado Rocky Mountain Health Plans members under UnitedHealthcare Pharmacy Clinical Pharmacy Programs.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTremfya (guselkumab) — Prior Authorization and Reauthorization Criteria

Policy CodePolicy N/A

Change TypeCoverage criteria added for ulcerative colitiswording updated to 'targeted immunomodulator' with example changes

Effective DateDec 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization for subcutaneous Tremfya; approvals are issued for 12 months when indication-specific criteria are met.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for ulcerative colitis were added.

Not receiving in combination language updated to 'targeted immunomodulator' with example list changes.

Background information updated.

12 monthsauthorization duration

4indications

2017–2025program review history

Coverage Criteria for Tremfya (guselkumab)

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Initial Therapy — Plaque Psoriasis

Covered when ALL of the following are met

Psoriasis initial: (1) Diagnosis of moderate to severe plaque psoriasis

Authorization issued for 12 months

Psoriasis initial: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]

Authorization issued for 12 months

Reauthorization — Plaque Psoriasis

Covered when ALL of the following are met

Psoriasis reauth: (1) Documentation of positive clinical response to Tremfya therapy

Authorization issued for 12 months

Psoriasis reauth: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]

Authorization issued for 12 months

Initial Therapy — Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic arthritis initial: (1) Diagnosis of active psoriatic arthritis

Authorization issued for 12 months

Psoriatic arthritis initial: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]

Authorization issued for 12 months

Reauthorization — Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic arthritis reauth: (1) Documentation of positive clinical response to Tremfya therapy

Authorization issued for 12 months

Psoriatic arthritis reauth: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast)]

Authorization issued for 12 months

Initial Therapy — Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative colitis initial: (1) Diagnosis of moderately to severely active ulcerative colitis

Authorization issued for 12 months

Ulcerative colitis initial: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), ustekinumab, adalimumab, Skyrizi (risankizumab)]

Authorization issued for 12 months

Reauthorization — Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative colitis reauth: (1) Documentation of positive clinical response to Tremfya therapy

Authorization issued for 12 months

Ulcerative colitis reauth: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), ustekinumab, adalimumab, Skyrizi (risankizumab)]

Authorization issued for 12 months

Initial Therapy — Crohn's Disease

Covered when ALL of the following are met

Crohn's initial: (1) Diagnosis of moderately to severely active Crohn's disease

Authorization issued for 12 months

Crohn's initial: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Skyrizi (risankizumab), ustekinumab]

Authorization issued for 12 months

Reauthorization — Crohn's Disease

Covered when ALL of the following are met

Crohn's reauth: (1) Documentation of positive clinical response to Tremfya therapy

Authorization issued for 12 months

Crohn's reauth: (2) Patient is not receiving Tremfya in combination with another targeted immunomodulator [e.g., adalimumab, Cimzia (certolizumab), Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Skyrizi (risankizumab), ustekinumab]

Authorization issued for 12 months

Requests for Tremfya (guselkumab) will not be approved when the patient is receiving Tremfya in combination with another targeted immunomodulator. Examples of agents considered targeted immunomodulators in this program include, but are not limited to, Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast), Entyvio (vedolizumab), and Omvoh (mirikizumab-mrkz).

Use of Tremfya concomitantly with another targeted immunomodulator is an exclusion to coverage and may result in denial of prior authorization.

Initial Therapy — All Indications

Initial authorization rules by indication require both diagnosis and absence of concomitant targeted immunomodulator use.

Initial therapy: Diagnosis of the specified condition (per indication-specific criteria) AND not receiving Tremfya in combination with another targeted immunomodulator

Authorization issued for 12 months

Reauthorization / Continuation Therapy

Reauthorization requires evidence of clinical benefit and absence of concomitant targeted immunomodulator use.

Continuation therapy: Documentation of positive clinical response to Tremfya therapy AND not receiving Tremfya in combination with another targeted immunomodulator

Authorization issued for 12 months

Provider Actions, Prior Authorization, and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for subcutaneous Tremfya. When indication-specific criteria are met, authorization will be issued for 12 months.

Authorization duration: 12 months

Step Therapy

Program-level Step Therapy / Automated Approval Note

Supply limits, Step Therapy, and/or Medical Necessity may apply. UnitedHealthcare (program-level) may use automated approval or reauthorization based on prior claim/medication history, diagnosis codes (ICD-10), and/or claim logic; use of automated processes varies by program and therapeutic class.

Supply limits and step therapy may be enforced
Automated approval/re-approval may occur based on claims history and diagnosis

Documentation Required

Reauthorization — Clinical Response Required

For reauthorization, documentation of positive clinical response to Tremfya therapy is required. Where specified (e.g., ulcerative colitis, Crohn's disease), reauthorization also requires confirmation that the patient is not receiving Tremfya in combination with another targeted immunomodulator.

Reauthorization requires documentation of positive clinical response
Some indications require both positive response and absence of concomitant targeted immunomodulator therapy

Denial Risk

Concomitant Targeted Immunomodulator Exclusion

Requests will be denied when the patient is receiving Tremfya in combination with another targeted immunomodulator. Examples include, but are not limited to: Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, ustekinumab, Skyrizi (risankizumab), Cosentyx (secukinumab), Taltz (ixekizumab), Siliq (brodalumab), Ilumya (tildrakizumab), Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), Otezla (apremilast), Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Omvoh (mirikizumab-mrkz) and others as listed in indication-specific criteria.

Concomitant targeted immunomodulators are exclusionary
Examples of excluded concurrent agents are listed in indication-specific criteria