Quick answer
J1628
What Medicare pays for Tremfya (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J1628 | Inj., guselkumab, 1 mg | 1 mg | $66.920 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Worked billing example for Tremfya
A concrete, paste-checkable example using J1628’s own billing-unit basis and vial sizes — not a hypothetical.
| Scenario | 100 mg SC maintenance dose (psoriasis/PsA, q8wk) |
| Dose administered | 100 mg |
| Billing unit basis | 1 unit = 1 mg |
| Billing units (dose ÷ unit basis, rounded up) | 100 units of J1628 |
| Vial combination drawn (min-waste plan) | 1 × 100 mg vial |
| Discarded (waste) | None |
| Wastage modifier (JW / JZ) | Bill all 100 units on a single line with JZ (attests zero drug discarded). What JZ/JW mean → |
| Medicare allowable (ASP + 6%, 2026 Q3) | 100 units × $66.920/unit = $6692.00 |
This is Medicare’s allowable payment limit (ASP + 6%, 2026 Q3) — not a promise of what you will be paid. Actual paid amount depends on sequestration and whether the claim carries a covered diagnosis.
Dose source: drugs/tremfya.html — FAQ: "The 100 mg SC maintenance dose is billed as 100 units.". Different dose or drug? Compute your own dose → or estimate the full cost & patient out-of-pocket →.
Tremfya is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J1628) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Tremfya
The 5 FDA-approved indications for J1628, grouped by condition — filter to find a code.
Plaque Psoriasis — 1 diagnoses (applies to J1628)
Diseases of the skin & subcutaneous tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| L40.0 | Psoriasis vulgaris |
Psoriatic Arthritis — 2 diagnoses (applies to J1628)
Diseases of the skin & subcutaneous tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| L40.50 | Arthropathic psoriasis, unspecified |
Diseases of the musculoskeletal system & connective tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| M07.30 | Unspecified psoriatic arthropathy, unspecified site |
Psoriasis — 1 diagnoses (applies to J1628)
Diseases of the skin & subcutaneous tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| L40.9 | Psoriasis, unspecified |
Enteropathic Arthritis — 1 diagnoses (applies to J1628)
Diseases of the musculoskeletal system & connective tissue (1)
| ICD-10 | Covered diagnosis |
|---|---|
| M07.60 | Enteropathic arthropathies, unspecified site |
What commercial payers require for Tremfya
Medicare Part B is only half the answer — most Tremfya claims are adjudicated by a commercial plan with its own medical policy. Below is what 24 commercial payers publish for Tremfya, read from each payer's own policy document. 22 of 24 that state a position require prior authorization, and 5 run a site-of-care program that can push the infusion out of the hospital outpatient setting.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | — | 2 | 2026-06-29 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 2 | 2026-01-01 |
| BCBS Kansas policy ↗ | Required | — | Site-of-care program applies | 2 | — |
| BCBS Louisiana policy ↗ | Not required | — | — | 2 | 2026-05-01 |
| BCBS Michigan policy ↗ | Required | — | Site-of-care program applies | 2 | 2026-07-01 |
| BCBS Minnesota policy ↗ | Required | — | — | 2 | 2026-03-03 |
| BCBS Mississippi policy ↗ | Required | — | — | 1 | 2025-08-01 |
| BCBS Nebraska policy ↗ | Required | — | — | 2 | 2025-11-05 |
| BCBS South Carolina policy ↗ | Required | — | Site-of-care program applies | 2 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 2 | 2026-03-03 |
| Blue Shield of California policy ↗ | Required | — | preferred_site_required | 2 | 2026-02-01 |
| Capital BlueCross policy ↗ | Required | — | — | 2 | 2026-03-03 |
| CareFirst BCBS policy ↗ | Required | — | — | 2 | — |
| Cigna policy ↗ | Required | — | — | 2 | 2026-03-15 |
| Excellus BCBS policy ↗ | Required | — | — | 2 | 2026-06-23 |
| Florida Blue policy ↗ | Required | — | — | 2 | 2026-07-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Required | — | — | 2 | 2026-06-15 |
| Highmark BCBS policy ↗ | Required | — | — | 2 | 2026-08-03 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | 2 | 2026-02-23 |
| Independence Blue Cross policy ↗ | Not required | — | — | 2 | 2025-07-01 |
| Premera Blue Cross policy ↗ | Required | — | — | 2 | 2026-06-01 |
| Regence BCBS policy ↗ | Required | — | dru408 | 2 | 2026-04-01 |
| UnitedHealthcare policy ↗ | Required | — | — | 2 | 2026-05-01 |
| Wellmark BCBS policy ↗ | Required | — | — | 2 | 2025-12-20 |
What Tremfya payers put in writing
Quoted from the medical policies linked above — 26 distinct requirements across 24 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Member cannot use the requested medication concomitantly with any other biologic drug or targeted synthetic drug
— Aetna, BCBS Tennessee and 3 other payers policy ↗Member has had a documented negative tuberculosis (TB) test (which can include a tuberculosis skin test [TST] or an interferon-release assay [IGRA]) within 12 months of initiating therapy for persons who are naïve to biologic drugs or targeted synthetic drugs associated with an increased risk of TB.
— BCBS Tennessee, CareFirst BCBS and 2 other payers policy ↗Ulcerative colitis and Crohn's disease: gastroenterologist
— Aetna, BCBS Tennessee, CareFirst BCBS policy ↗Not to be used in combination with other biologics or targeted disease-modifying anti-rheumatic drugs (DMARDs).
— BCBS Kansas, BCBS Michigan, BCBS South Carolina policy ↗Prescribed by or in consultation with a gastroenterologist
— Blue Shield of California, Independence Blue Cross, UnitedHealthcare policy ↗Treatment with an adequate course of conventional therapy (such as NSAIDs, DMARDs) has been ineffective, is contraindicated, or not tolerated
— BCBS Kansas, BCBS South Carolina policy ↗
Prior authorization
Coverage is provided when the criteria below are met
— BCBS Kansas, BCBS South Carolina policy ↗Precertification of intravenous guselkumab (Tremfya IV) is required of all Aetna participating providers
— Aetna policy ↗Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of Tremfya
— BCBS Federal Employee Program policy ↗Initiation of intravenous (IV) guselkumab (Tremfya) meets the definition of medical necessity when ALL of the following criteria are met
— Florida Blue policy ↗Target Agent(s) will be approved when ALL of the following are met
— HCSC (IL/TX/OK/NM/MT) policy ↗Line of Business PA Required in Medical Management System (Yes/No) BCBS Yes BCN Yes MAPPO No BCNA No
— BCBS Michigan policy ↗
Quantity and frequency limits
Quantity Limits: Align with FDA recommended dosing
— BCBS Kansas, BCBS Michigan, BCBS South Carolina policy ↗200 mg IV every 4 weeks for a total of 3 doses (i.e., Week 0, Week 4, and Week 8)
— Florida Blue policy ↗Tremfya guselkumab iv soln 200 MG/20ML
— HCSC (IL/TX/OK/NM/MT) policy ↗400 billable units at weeks 0, 4, and 8, then 200 billable units every 28 days
— Capital BlueCross policy ↗Authorization of 12 months may be granted for treatment of moderately to severely active ulcerative colitis.
— CareFirst BCBS policy ↗Authorization of 12 months may be granted for treatment of moderately to severely active Crohn’s disease.
— CareFirst BCBS policy ↗
Dosing rules
For Tremfya intravenous requests only: Dosage is 200 mg at week 0, week 4, and week 8.
— BCBS Louisiana policy ↗Simponi® injections for the two weeks (Day 0 200mg and Day 15 100mg) and a maintenance
— BCBS Mississippi policy ↗In CD and UC, a three-dose induction regimen (200 mg at Weeks 0, 4, and 8) is
— Cigna policy ↗National Drug Code How Supplied 57894-0650-02 200 mg/ 20 mL vial Diagnosis
— UnitedHealthcare policy ↗Loading doses: 200 mg by intravenous infusion at weeks 0, 4, and 8
— Wellmark BCBS policy ↗
Reauthorization / continuation
Authorization of 12 months may be granted for all members (including new members) who are using the requested medication for moderately to severely active ulcerative colitis and who achieve or maintain remission.
— BCBS Tennessee, CareFirst BCBS, Wellmark BCBS policy ↗Renewal Criteria: Clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit
— BCBS Michigan policy ↗Renewal: Prior authorization validity may be renewed every 12 months (365 days) thereafter for subcutaneous maintenance.
— Capital BlueCross policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Tremfya
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J1628. Matching codes, units and JZ/JW wastage →
Which policy governs Tremfya
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Tremfya is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J1628, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Tremfya covered by Medicare?
- Yes. Tremfya (J1628) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Tremfya (J1628)?
- Medicare publishes no drug-specific covered-diagnosis list for J1628. The 5 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Tremfya?
- No drug-specific LCD or Billing & Coding Article exists for Tremfya. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Tremfya claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J1628. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Tremfya's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Tremfya cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Tremfya — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Tremfya prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Tremfya”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.