CurrentAvMedPolicy Pub. 100-2

Cosentyx (secukinumab) IV prior authorization (Medical)

Form and clinical checklist governing prior authorization and step-edit approval for Cosentyx IV (secukinumab) for AvMed members; applies to providers requesting medical benefit coverage for the IV formulation.

Policy Summary

PayerAvMed

PolicyCosentyx (secukinumab) IV prior authorization (Medical)

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrescribing physician must complete, sign, and fax the prior authorization form and provide supporting documentation, including lab results and chart notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3indications listed

Two NSAIDsrequired prior trial

300 mgmax maintenance dose

90 daysestablished use duration

Coverage Criteria for Cosentyx (secukinumab) IV

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

AS initial therapy: Member is ≥ 18 years of age; member has a diagnosis of active ankylosing spondylitis; prescribed by or in consultation with a Rheumatologist; member tried and failed, has a contraindication, or intolerance to TWO NSAIDs; member meets ONE of the following: tried and failed, has a contraindication, or intolerance to TWO of the preferred biologics (adalimumab products (Humira, Cyltezo, Hyrimoz), Enbrel, Rinvoq, Taltz, Xeljanz/XR) OR member has been established on Cosentyx IV for at least 90 days (evidenced by medical claims history).

Non-radiographic axial spondyloarthritis - Initial Therapy

Covered when ALL of the following are met for Non-radiographic Axial Spondyloarthritis:

nr-axSpA initial therapy: Member is ≥ 18 years of age; member has a diagnosis of active non-radiographic axial spondyloarthritis; prescribed by or in consultation with a Rheumatologist; member has at least ONE objective sign of inflammation (elevated CRP OR sacroiliitis on MRI); member tried and failed, has a contraindication, or intolerance to TWO NSAIDs; member meets ONE of the following: tried and failed, has a contraindication, or intolerance to TWO of the preferred biologics (e.g., Cimzia SQ, Rinvoq, Taltz) OR member has been established on Cosentyx IV for at least 90 days (evidenced by medical claims history).

Psoriatic Arthritis - Initial Therapy

Covered when ALL of the following are met for Psoriatic Arthritis (PsA):

PsA initial therapy: Member is ≥ 18 years of age; member has a diagnosis of active psoriatic arthritis; prescribed by or in consultation with a Rheumatologist or Dermatologist; member has tried and failed at least ONE DMARD for ≥ 3 months (cyclosporine, leflunomide, methotrexate, sulfasalazine); member meets ONE of the following: tried and failed, has a contraindication, or intolerance to TWO of the preferred biologics (adalimumab products (Humira, Cyltezo, Hyrimoz), Enbrel, Otezla, Rinvoq, Skyrizi, Stelara, Taltz, Tremfya, Xeljanz/XR) OR member has been established on Cosentyx IV for at least 90 days (evidenced by medical claims history).

Dosing

Dosing options (choose one):

dosing options: With loading dose: 6 mg/kg at Week 0 as a loading dose, followed by 1.75 mg/kg every 4 weeks thereafter (max. maintenance dose 300 mg per infusion); Without loading dose: 1.75 mg/kg every 4 weeks (max. maintenance dose 300 mg per infusion).

The Health Plan considers concomitant therapy with more than one biologic immunomodulator (for example, Dupixent, Entyvio, Humira, Rinvoq, Stelara) to be experimental and investigational. Safety and efficacy of using multiple biologic immunomodulators together have not been established and such combinations will not be permitted.

Use of more than one biologic immunomodulator concurrently, whether prescribed for the same indication or for different indications, is considered experimental and investigational by the Health Plan. Because safety and efficacy data for these concurrent combinations are lacking, requests that involve overlapping biologic immunomodulators will be denied/not permitted.

Coding and Dosing Summary

Covered HCPCS CodesHCPCSCovered

C9166

Cosentyx (secukinumab) IV

inv-08: Maximum maintenance dose — 300 mg per infusion.

Maximum maintenance dose300 mg per infusion

Loading dose regimen (context)With loading dose: 6 mg/kg at Week 0 then 1.75 mg/kg every 4 weeks (max maintenance 300 mg/infusion)

No-loading regimen (context)Without loading dose: 1.75 mg/kg every 4 weeks (max maintenance 300 mg/infusion)

inv-09: Adult age requirement — ≥ 18 years of age.

Adult age requirement≥ 18 years of age

Applies to indicationsRequirement listed for Ankylosing Spondylitis, Non-radiographic axial spondyloarthritis, and Psoriatic Arthritis

VerificationAge must be documented on the prior authorization form

Provider Requirements and Prior Authorization Process

Prior Authorization

Prior Authorization Required

Medical prior authorization required — Prior authorization form must be completed and signed by the prescribing physician (preprinted stamps not valid). The prescriber must print and sign their name; all other information may be filled in by office staff. Fax the completed form to 1-877-535-1391. Cosentyx IV (C9166) is a medical benefit; follow medical billing and submission instructions. For Medicare members, comply with Pub. 100-2 Chapter 15 §50 and any applicable NCDs/LCDs: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

Fax: 1-877-535-1391
Drug: Cosentyx® (secukinumab) IV (C9166) (Medical)
Medicare guidance: Pub. 100-2 Chapter 15 §50; CMS coverage database

Step Therapy

Required Prior Therapy / Established Use

Member must have failed, have a contraindication to, or intolerance of required prior therapies where specified (e.g., TWO NSAIDs for axial disease, required prior biologic or DMARD trials for psoriatic arthritis). Verification will be via chart notes and/or pharmacy paid claims. Member may qualify for continuation if established on Cosentyx IV for at least 90 days as evidenced by medical claims history.

Axial disease: failure/intolerance to TWO NSAIDs
Psoriatic arthritis: trial and failure of at least ONE DMARD for ≥3 months (e.g., methotrexate, sulfasalazine, leflunomide, cyclosporine)
Preferred biologics required failures where listed (e.g., adalimumab products, Enbrel, Taltz, Rinvoq, etc.)
Continuation: ≥90 days on Cosentyx IV per medical claims

Documentation Required

Signature and Supporting Documentation

Prescribing physician must sign and clearly print name on the prior authorization request (preprinted stamps not valid). To support each clinical criterion checked on the form, provide documentation including relevant lab results (e.g., CRP when requested), diagnostic test results, and chart notes. All required supporting documentation must be submitted with the request or the authorization may be denied.

Prescriber signature and printed name required (no stamps)
Include lab results, diagnostics, and chart notes supporting each checked criterion (e.g., CRP for signs of inflammation)
Prior therapies must be documented (chart notes or pharmacy paid claims)

Denial Risk

Incomplete or Illegible Information — Delay or Denial Risk

Authorization may be delayed or denied if required information is missing, incomplete, or illegible. Ensure the form includes working phone and fax numbers, NPI, member identifiers, dates (e.g., date of weight if applicable), diagnosis and ICD code, and any other requested fields. For urgent review, contact AvMed Pre-Authorization Department when lack of treatment could seriously jeopardize life, health, or ability to regain maximum function.

Incomplete/illegible forms, missing phone/fax, missing documentation, or absent lab results can delay or cause denial
Include Member AvMed #, DOB, provider NPI, and contact info
For urgent reviews contact AvMed Pre-Authorization Department

Definitions and Concomitant Therapy

inv-15: Concomitant biologic therapy — Use of more than one biologic immunomodulator concurrently (e.g., Dupixent, Entyvio, Humira, Rinvoq, Stelara) which the Health Plan considers experimental/investigational.

DefinitionUse of more than one biologic immunomodulator concurrently (e.g., Dupixent, Entyvio, Humira, Rinvoq, Stelara)

Plan stanceThe Health Plan considers concurrent use of more than one biologic immunomodulator experimental and investigational and will NOT be permitted.

RationaleSafety and efficacy of these combinations has NOT been established

ScopeApplies whether biologics are prescribed for the same or different indications

Background

Cosentyx (secukinumab) IV is listed on this form as an intravenous biologic therapy intended for use in adults for conditions including ankylosing spondylitis, non-radiographic axial spondyloarthritis, and psoriatic arthritis. The form captures dosing options with or without a loading dose and specifies a maximum maintenance dose of 300 mg per infusion. Requests for Cosentyx IV are subject to prior authorization and the plan’s criteria for required prior therapies or established use.