Prior authorization required; include required documentation; 12‑month durations

Prior authorization is required for Cosentyx. Both initial and continuation requests must include the documentation elements listed under Required Documentation (e.g., chart notes/medical records showing affected areas and BSA for psoriasis; prior medications tried and responses or clinical reasons to avoid those therapies). Authorization durations for Cosentyx subcutaneous formulations are typically 12 months.

• Include chart notes/medical record documentation of affected area(s) and body surface area (BSA) when applicable (psoriasis).
• For initial requests, provide chart notes/medical record documentation or claims history of prior medications tried and responses, or documentation of clinical reasons to avoid therapy.
• For continuation requests, provide documentation of decreased BSA and/or improvement in signs and symptoms or other measures of positive clinical response.
• Typical authorization duration: 12 months for subcutaneous formulations.

Continuation authorization — 12 months for responders

Continuation authorization may be granted for 12 months for members using Cosentyx subcutaneous formulations who achieve or maintain a positive clinical response as evidenced by low disease activity or improvement in signs and symptoms.

• Plaque psoriasis: reduction in BSA affected or improvement in signs/symptoms (e.g., itching, redness, scaling).
• Psoriatic arthritis: improvement in swollen/tender joint counts, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRP.

Step therapy — document inadequate response/intolerance to preferred agents

Many indications require documented inadequate response or intolerable adverse events to preferred or first‑line agents (examples include Avsola, Inflectra, Simponi Aria, Skyrizi, TNF inhibitors, conventional systemic agents, NSAIDs, or antibiotics depending on indication) prior to approval of Cosentyx.

• Psoriatic arthritis and ankylosing spondylitis initial approvals: documented inadequate response or intolerable adverse event to specified preferred agents (Avsola, Inflectra, Simponi Aria, Skyrizi) or documented clinical reason to avoid TNF inhibitors plus inadequate response to Skyrizi.
• Hidradenitis suppurativa: inadequate response to an oral antibiotic for at least 90 days or intolerance/contraindication to oral antibiotics; prior biologic for HS may also satisfy initial approval.
• Intravenous Cosentyx requests default to preferred IV products (Avsola, Inflectra, Skyrizi, Simponi Aria) unless a clinical exception is documented.

Documented clinical reasons to avoid comparator agents (see appendices)

Clinical reasons listed in the appendices may justify avoiding certain agents and inform selection of Cosentyx (e.g., reasons to avoid TNF‑inhibitors or reasons to avoid methotrexate/cyclosporine/acitretin/leflunomide).

• Appendix A examples to avoid TNF inhibitors: history of congestive heart failure, demyelinating disorder, hepatitis B infection, risk of lymphoma, autoantibody formation/lupus‑like syndrome.
• Appendix B examples to avoid methotrexate/cyclosporine/acitretin/leflunomide: pregnancy or planning pregnancy, breastfeeding, chronic liver disease or alcohol use disorder, drug interactions, significant comorbidity, history of intolerance or hypersensitivity.

Required documentation — chart notes, BSA, prior meds and responses

Submit chart notes or medical records that document the condition and prior treatment history: affected areas and BSA for psoriasis, prior medications tried and responses (or clinical reasons to avoid those therapies), and supporting notes for continuation requests showing clinical benefit.

• Initial requests: chart notes/claims history of prior medications tried and response; if a therapy is not advisable, include clinical reason to avoid that therapy.
• Plaque psoriasis initial: documentation of affected areas and BSA (when applicable).
• Continuation requests: documentation of decreased BSA and/or improvement in signs and symptoms or other condition‑specific response measures.

Document clinical response — baseline and follow‑up measures required

Document baseline and follow‑up measures that demonstrate improvement or low disease activity appropriate to the indication (e.g., BSA for plaque psoriasis; joint counts, dactylitis, enthesitis, axial findings, skin/nail involvement, functional status, or CRP for psoriatic arthritis).

• Plaque psoriasis: reduction in BSA and improvement in signs/symptoms (itching, redness, flaking, scaling, burning, cracking, pain).
• Psoriatic arthritis: improvement in number of swollen/tender joints, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRP.
• ERA, AS/axSpA, HS: use the indication‑specific measures listed in the policy (e.g., flares, joint counts, spinal pain, abscess/nodule counts, frequency of lesions, pain, QoL or disease severity tools).

TB test documentation — negative TST or IGRA within 12 months for biologic/ts‑naive persons

Provide a documented negative tuberculosis test (TST or IGRA) within 12 months prior to initiating therapy for persons naive to biologic or targeted synthetic therapies.

• A positive TB screening requires further testing (e.g., chest X‑ray) to exclude active disease before initiating therapy.
• Do not administer Cosentyx to members with active TB; latent TB must be treated prior to starting therapy.

Missing documentation may lead to PA denial

Failure to submit the required documentation (e.g., chart notes, BSA, prior medication history, documentation of response) may result in denial of the prior authorization request.

• Ensure initial requests include prior medication history or clinical reasons to avoid therapies; ensure continuation requests include objective measures of response.

TB screening and concomitant therapy — do not start if active TB; follow-up testing/treatment required

Do not administer Cosentyx to members with active tuberculosis. If TB screening is positive, perform further testing to exclude active disease (e.g., chest X‑ray) and initiate TB treatment for latent infection before starting the medication. Members may not use Cosentyx concomitantly with another biologic or targeted synthetic drug for the same indication.

• Positive TB screen → further testing to confirm no active disease; treat latent TB prior to initiation.
• Concomitant use with other biologic or targeted synthetic drugs for the same indication is prohibited.

Not medically necessary if criteria unmet

Cosentyx is considered not medically necessary for members who do not meet the policy criteria; ensure all applicable criteria and documentation are met to avoid a not‑medically‑necessary determination.

• Members receiving samples or patient assistance must still meet initial approval criteria when seeking coverage.