Tremfya — Medical Mutual

Initial criteria

• Patient age > 18 years AND
• Tremfya is prescribed by or in consultation with a rheumatologist or dermatologist
• Site of care medical necessity is met

Reauthorization criteria

• Patient has been established on Tremfya ≥ 6 months AND
• Patient meets at least ONE: objective beneficial clinical response compared with baseline (e.g., DAPSA, CPDAI, PsA DAS, Grace Index, LEI, SPARCC, Leeds Dactylitis, MDA, PsAID-12, serum markers) OR clinical improvement in at least one symptom (e.g., less joint pain, morning stiffness, fatigue, improved function, decreased swelling)
• Site of care medical necessity is met

Approval duration

initial 6 months; reauth 1 year