Western Health Advantage - All plan years
Tremfya (guselkumab)
Drugs for the Skin : Drugs for the Skin
  • Diabetic Medical Supplies:
    Duration: 12 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)

  • Available through Specialty Pharmacy;
  • PA applies for members age 35 and older;
  • ST Applies
  • Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), Rheumatoid Arthritis (RA):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Crohn's Disease (CD):
    Age Requirement: >= 6
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Hidradenitis Suppurativa (HS):
    Age Requirement: >= 12
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialty Pharmacy Provider(s): CVS Specialty
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified

    Juvenile Idiopathic Arthritis:
    Age Requirement: >= 2
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Psoriasis (PsO):
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes
    History of Plaque Psoriasis: N/A
    Overall % of Body Surface For Initiation: 3
    Overall % of Body Surface For Initiation With Sensitive Areas: 3
    Psoriasis Classification: chronic.,moderate to severe
    Sensitive Area BSA Percent override: No

    Ulcerative Colitis (UC):
    Age Requirement: >= 5
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified
    TB Test required: Yes

    Uveitis:
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Quantity Limit: 30 grams per 30 day(s).