Prior authorization required for Cosentyx

Prior authorization is required for Cosentyx; initial and continuation requests must include the documentation specified in the policy and meet the indication-specific criteria (see Required Documentation and coverage criteria).

• Initial and continuation requests must meet the indication-specific criteria (e.g., prior trials, disease severity, age limits).
• Submit required documentation (chart notes, prior medication history, BSA when applicable) as detailed in the policy.

12-month approvals for responders (documentation required)

When positive clinical response or low disease activity is documented, prior authorization approvals may be granted for 12 months for multiple indications; documentation must compare response to baseline and cite specific improved measures per indication.

• 12-month authorizations may be granted for PsO, PsA, AS/nr-axSpA, ERA, and HS (subcutaneous formulations only for some indications) when criteria are met.
• Evidence of improvement must compare to baseline (e.g., swollen/tender joints, functional status, BSA, pain, abscess counts, CRP).

Step therapy / prior trials required

Step therapy is required for many indications: the member must have documented inadequate response or intolerance to specified preferred products or conventional therapies before Cosentyx is approved, unless there is a documented clinical reason to avoid those alternatives.

• Preferred IV alternatives (Avsola, Inflectra, Simponi Aria, Skyrizi) are required trials for certain IV requests.
• Conventional therapies (e.g., methotrexate, NSAIDs, sulfasalazine, oral antibiotics for HS) must be tried when indicated or a clinical reason to avoid must be documented.

Equitable treatment regardless of samples or assistance

Members receiving samples or manufacturer assistance must meet the same initial approval criteria as other members; providers must document that these criteria are met.

• Ensure members on samples/patient assistance have documentation of prior trials, disease severity, and other required criteria before submitting for authorization.

Required documentation for initial and continuation requests

Submit chart notes or medical record documentation for initial and continuation requests: affected areas and BSA (when applicable), prior medication trials and responses or reasons to avoid therapies for initial requests, and documentation of positive clinical response or decreased BSA for continuation requests.

• Initial requests: chart notes/records of affected area(s), BSA, prior medications tried and response, or clinical reason to avoid therapies.
• Continuation requests: chart notes documenting decreased BSA and/or clinical improvement compared with baseline.

Document evidence of clinical response vs baseline

Provide documentation of clinical response that compares to baseline and demonstrates improvement or low disease activity using disease-specific measures appropriate to the indication.

• PsA: improvement in swollen/tender joint counts, dactylitis, enthesitis, axial disease, skin/nail involvement, functional status, or CRP.
• AS/nr-axSpA: improvement in functional status, total spinal pain, or inflammation (e.g., morning stiffness).
• ERA and HS: use the listed measures (e.g., number of flares, abscess/nodule counts, pain, quality of life) compared to baseline.

TB testing documentation required before initiation

Document a negative TB screen (TST or IGRA) within 12 months prior to initiating therapy for persons naïve to biologic or targeted synthetic drugs; if screening is positive, obtain further testing to exclude active disease and treat latent TB prior to initiation.

• If TB screening is positive, obtain confirmatory testing (e.g., chest x-ray) and do not start Cosentyx if active TB is present.
• If latent TB is identified, TB treatment must be started before initiating the requested medication.

Incomplete documentation may result in denial

Failure to submit required documentation (chart notes, BSA, prior medication history, or evidence of response) may prevent prior authorization review or lead to denial of initiation or continuation.

• Ensure all required chart notes, medication history, baseline measures, and response documentation are included with the authorization request to avoid denial.

Do not start therapy with active TB; positive screen requires follow-up

Do not administer Cosentyx to members with active TB infection; a positive TB screen requires further testing and treatment prior to initiation and active disease is a contraindication to therapy.

• If screening testing for TB is positive, obtain further testing (e.g., chest x-ray) to confirm no active disease before considering initiation.

Concomitant biologic/tsDMARD use not permitted

Concomitant use of Cosentyx with any other biologic or targeted synthetic drug for the same indication is not allowed and will result in a non-covered determination.

• Verify patient is not receiving another biologic or targeted synthetic drug for the same indication before approving or administering Cosentyx.