Blue Cross Blue Shield TN Secukinumab Coverage

Coverage and Clinical Criteria

Initial Therapy - Plaque psoriasis (PsO)

Covered when ANY of the following are met for members 6 years and older

Plaque Psoriasis coverage options: At least 10% of body surface area (BSA) is affected.ages >=6 years

Authorization of 12 months may be granted.

Plaque Psoriasis coverage options: Crucial body areas are affected (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas).ages >=6 years

Authorization of 12 months may be granted.

Plaque Psoriasis coverage options: At least 3% of body surface area (BSA) is affected AND any of the following: inadequate response or intolerance to phototherapy (e.g., UVB, PUVA) or to methotrexate, cyclosporine, or acitretin; OR a clinical reason to avoid methotrexate, cyclosporine, and acitretin.ages >=6 years

Authorization of 12 months may be granted; see Appendix for clinical reasons to avoid therapies.

Initial Therapy - Psoriatic arthritis (PsA)

Covered when ONE of the following is met for members 2 years and older

Psoriatic arthritis coverage options: Member has mild to moderate disease AND one of: inadequate response to methotrexate, leflunomide, or another conventional synthetic DMARD administered at adequate dose/duration; OR intolerance/contraindication to methotrexate or leflunomide (or another conventional synthetic agent); OR presence of enthesitis or predominantly axial disease.ages >=2 years

Authorization of 12 months may be granted; prior biologic or targeted synthetic drug use noted as applicable.

Psoriatic arthritis coverage options: Member has severe disease.ages >=2 years

Authorization of 12 months may be granted; prior biologic or targeted synthetic drug use noted as applicable.

Initial Therapy — Top-level initial authorization rules by indication and age (grouping of initial therapy criteria)

Initial authorization rules by indication and age

Plaque psoriasis initial: Authorization of 12 months for members >=6 years when plaque psoriasis initial coverage criteria are met (see Plaque psoriasis criteria).

Providers must supply documentation of prior therapies tried or reasons to avoid them where applicable.

Psoriatic arthritis initial: Authorization of 12 months for members >=2 years when PsA initial coverage criteria are met (inadequate response or intolerance to conventional synthetic DMARDs, severe disease, or enthesitis/axial disease).

Providers must supply documentation of prior therapies tried or reasons to avoid them where applicable.

Ankylosing spondylitis/nr-axSpA initial: Authorization of 12 months for adult members when AS/nr-axSpA criteria are met (inadequate response to or intolerance/contraindication to ≥2 NSAIDs, or prior biologic/targeted synthetic drug use).

Prior biologic or targeted synthetic drug use may be required.

Initial therapy criteria — Initial authorization criteria that vary by indication and may require prior therapy failure or intolerance

Initial authorization criteria that vary by indication and may require prior therapy failure or intolerance

AS initial: Member has an intolerance or contraindication to two or more NSAIDs; OR member has had an inadequate response to at least two NSAIDs; OR member has previously received a biologic or targeted synthetic drug indicated for active AS or nr-axSpA.

Authorization of 12 months may be granted for adult members.

ERA initial: BOTH of the following must be met: (1) Member has active disease demonstrated by ≥3 active joints and ≥1 site of active enthesitis at baseline or documented by history; AND (2) Member has had an inadequate response to NSAIDs, sulfasalazine, or methotrexate OR has an intolerance/contraindication to NSAIDs, sulfasalazine, and methotrexate.

Authorization of 12 months may be granted for members >=4 years; see Appendix for contraindication examples.

HS initial: Member has an intolerance or contraindication to oral antibiotics used for HS; OR member has had an inadequate response to an oral antibiotic used for HS for at least 90 days (e.g., clindamycin, metronidazole, moxifloxacin, rifampin, tetracyclines).

Initial therapy (IV) — Initial intravenous dosing for adults

Initial intravenous dosing for adults.

Initial IV dosing: Initial: 6 mg/kg on week 0 for adult patients (intravenous route).6 mg/kg

Weight‑based IV loading dose; prior authorization required to ensure dosing matches medication quantity limits.

inv-03: Plaque psoriasis — Continuation Therapy

Authorization of 12 months may be granted for members 6 years or older

Continuation criteria: Chart notes or medical documentation supporting decreased BSA and/or improvement in signs and symptoms or general positive clinical response are required for continuation approvals.

Typical authorization length is 12 months.

Plaque psoriasis continuation: Improvement in signs and symptoms from baseline (e.g., itching, redness, flaking, scaling, burning, cracking, pain).

Authorization of 12 months may be granted when improvement demonstrated.

Plaque psoriasis continuation: Reduction in body surface area (BSA) affected from baseline.

Authorization of 12 months may be granted when reduction demonstrated.

inv-04: Psoriatic arthritis — Continuation Therapy

Authorization of 12 months may be granted for members 2 years or older

PsA response: Improvement in number of tender joints from baseline.

Authorization of 12 months may be granted when improvement demonstrated.

PsA response: Improvement in number of swollen joints from baseline.

Authorization of 12 months may be granted when improvement demonstrated.

PsA response: Improvement in dactylitis, axial disease, enthesitis, skin and/or nail involvement, C‑reactive protein (CRP), or functional status from baseline.

Authorization of 12 months may be granted when improvement demonstrated.

Continuation documentation: Chart notes or medical documentation supporting positive clinical response are required for continuation approvals.

inv-05: Ankylosing spondylitis and nr-axSpA — Continuation Therapy

Authorization of 12 months may be granted for adult members

AS response: Improvement from baseline in total spinal pain, functional status, inflammation (e.g., morning stiffness), tender joints, swollen joints, or C‑reactive protein (CRP).

Chart notes documenting improvement are required for continuation approvals; typical authorization length is 12 months.

inv-06: Enthesitis-related arthritis — Continuation Therapy

Authorization of 12 months may be granted for members 4 years or older

ERA response: Improvement from baseline in number of joints with active arthritis, number of flares, number of joints with limited movement, enthesitis, or dactylitis.

Chart notes documenting improvement are required for continuation approvals; typical authorization length is 12 months.

inv-07: Hidradenitis suppurativa — Continuation Therapy

Authorization of 12 months may be granted for members 12 years or older

HS response: Improvement from baseline demonstrated by reduced formation of new sinus tracts and scarring; reduction in abscess and inflammatory nodule count; decrease in frequency of inflammatory lesions; reduction in pain; improvement in frequency of relapses; reduction in suppuration; improvement in quality of life; or improvement on a disease severity assessment tool.

Chart notes documenting improvement are required for continuation approvals; typical authorization length is 12 months.

inv-37: Continuation Therapy — Continuation (renewal) requirements

Continuation (renewal) requirements

Documentation required: Chart notes or medical record documentation demonstrating clinical improvement (e.g., decreased BSA, improved signs/symptoms, or indication‑specific measures) are required for continuation approvals.

Typical approval duration is 12 months.

Indication‑specific improvement examples: Plaque psoriasis: reduced BSA or improved signs/symptoms; PsA: improved tender/swollen joint counts, dactylitis, enthesitis, skin/nail disease, CRP, or function; AS/nr‑axSpA: improved pain, function, inflammation, joint counts, or CRP; ERA: improved joint involvement, flares, limited movement, enthesitis, or dactylitis; HS: improvements such as fewer abscesses/nodules, less suppuration, reduced scarring, reduced pain, fewer relapses, better quality of life, or improved disease severity score.

Provide supporting documentation with renewal requests.

inv-38: Continuation therapy criteria — Continuation approvals (typically 12 months) are granted when the member demonstrates improvement or low disease activity by indication-specific measures

Continuation approvals (typically 12 months) are granted when the member demonstrates improvement or low disease activity by indication-specific measures

Plaque psoriasis continuation: Improvement in signs and symptoms or reduction in BSA from baseline.

Authorization typically granted for 12 months when documented.

PsA continuation: Improvement in joint counts, dactylitis, enthesitis, skin/nail disease, CRP, or functional status.

Authorization typically granted for 12 months when documented.

AS continuation: Improvement in pain, function, inflammation, joint counts, or CRP.

Authorization typically granted for 12 months when documented.

ERA continuation:

All indications not specifically listed as FDA‑approved indications or recognized compendial uses in this policy are considered experimental/investigational and are not medically necessary for Blue Cross Blue Shield of Tennessee members.

Secukinumab should not be administered to members with active tuberculosis infection. Prior to initiating therapy, document a negative TB test (TST or IGRA) within 12 months for biologic- or targeted‑synthetic–naïve persons; if TB screening is positive, perform further evaluation (e.g., chest x‑ray) to exclude active disease and treat latent TB before starting secukinumab.

Intravenous dosing that exceeds the stated maximum maintenance dose is outside the medication quantity limits. The policy specifies a maximum maintenance dose of 300 mg per infusion for the IV regimen (maintenance: 1.75 mg/kg every 4 weeks, with initial IV dose 6 mg/kg at week 0), and requests exceeding this per‑infusion maximum may be denied.

Use of secukinumab for indications other than those listed as FDA‑approved indications or accepted compendial uses in this policy is considered not medically necessary and may be denied.

Key Definitions and Thresholds

BSA — Body surface area thresholds used to define severity and eligibility for plaque psoriasis coverage

BSA threshold (primary)At least 10% of body surface area (BSA) affected.

BSA threshold (secondary)Crucial body areas affected (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas).

Lower BSA with additional criteriaAt least 3% BSA affected AND inadequate response or intolerance to phototherapy (e.g., UVB, PUVA) or methotrexate, cyclosporine, or acitretin, or clinical reason to avoid those therapies.

Active enthesitis-related arthritis (ERA) — Definition used in policy (disease activity criteria)

Active ERA definition (joint involvement)Active disease demonstrated by at least three active joints involved.

Active ERA definition (enthesitis)

Codes and Coding Notes

Codes referencedmixed

N/A	No specific CPT/HCPCS/ICD-10/NDC codes listed in this section of the document.

Body Surface Area (BSA) — At least 10% BSA affected or at least 3% BSA with additional criteria

Primary BSA criterionAt least 10% BSA affected.

Crucial body area involvementDisease affecting hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas qualifies.

3% BSA plus additional requirementsAt least 3% BSA affected AND either inadequate response/intolerance to phototherapy or methotrexate, cyclosporine, or acitretin, or clinical reason to avoid those therapies.

Maximum maintenance dose per infusion — 300 mg

Maximum maintenance dose300 mg per infusion.

Maintenance dosing schedule1.75 mg/kg every 4 weeks (weight‑based), not to exceed 300 mg per infusion.

Provider Requirements and Documentation

Prior Authorization

Prior authorization required

Prior authorization is required for secukinumab (Cosentyx) for the listed indications; when coverage criteria are met, authorization of up to 12 months may be granted.

Prior Authorization

Authorization duration — typically 12 months

Approvals are typically granted for 12 months when the clinical criteria for the requested indication are met; continuation approvals are also generally granted for 12 months when positive clinical response or low disease activity is documented.

Prior Authorization

Prior authorization required for Cosentyx IV dosing

Prior authorization is required for intravenous Cosentyx to confirm the request matches the specified IV regimens and medication quantity limits (initial IV loading and maintenance dosing, and maximum maintenance dose).

Step Therapy Requirements

Requirement	Details
Step therapy must be followed per the external 'Step Therapy Requirements for Provider Administered Specialty Medications' guide.
Refer to the Step Therapy Requirements for Provider Administered Specialty Medications document at: https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf

Indication	Required prior trial or documented intolerance/contraindication
Ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA)
Intolerance/contraindication to two or more NSAIDs or inadequate response to at least two NSAIDs; prior biologic or targeted synthetic drug use may also be acceptable.
Enthesitis-related arthritis (ERA)
Inadequate response to NSAIDs, sulfasalazine, or methotrexate, or intolerance/contraindication to NSAIDs, sulfasalazine, and methotrexate; prior biologic use for active ERA is an alternative pathway.
Hidradenitis suppurativa (HS)
Intolerance or contraindication to oral antibiotics used for HS, or inadequate response to an oral antibiotic for at least 90 days (e.g., clindamycin, metronidazole, moxifloxacin, rifampin, tetracyclines); prior biologic use is an alternative.

Statement	Notes
No specific step therapy sequence is listed within the IV dosing and medication quantity limit sections of this document.
Step therapy requirements are referenced elsewhere (see Step Therapy Requirements guide); the policy does not enumerate a step-by-step sequence in these chunks.

Dosing and Quantity Limits

Cosentyx (Secukinumab) intravenous — Initial and maintenance dosing; maximum maintenance per infusion

Initial IV dose (week 0)6 mg/kg on week 0 (adult initial intravenous dose).

Maintenance IV dose1.75 mg/kg every 4 weeks for maintenance.

Maximum maintenance dose per infusion300 mg per infusion (maximum allowed).

Cosentyx (Secukinumab) — Key IV dosing and maximum maintenance dose

Maximum maintenance dose300 mg per infusion.

Initial IV dose6 mg/kg on week 0.

Maintenance IV regimen

Site of Care and Administration

Step Therapy

Subject to step therapy; no site restriction stated

Subject to the external Step Therapy Requirements for Provider Administered Specialty Medications; the policy does not impose an explicit site‑of‑care restriction for provider‑administered specialty medications.

Billing Rule

IV route specified; setting not explicitly restricted

The intravenous regimens specified in the policy identify intravenous administration for adults; the policy does not explicitly restrict the setting (e.g., infusion center) where IV administration must occur.

IV route: initial 6 mg/kg (week 0) and maintenance 1.75 mg/kg every 4 weeks.

Background

Secukinumab (Cosentyx) is an interleukin‑17A biologic indicated for multiple immune‑mediated inflammatory conditions including moderate to severe plaque psoriasis (≥6 years), psoriatic arthritis (≥2 years), ankylosing spondylitis and non‑radiographic axial spondyloarthritis in adults, enthesitis‑related arthritis (≥4 years), and hidradenitis suppurativa (≥12 years). Coverage under this policy is limited to those FDA‑approved indications and compendial uses when the specific clinical criteria are met.

Revision History

2026-09-01policy_implementationLatest

Policy implementation effective date established for this Secukinumab (Cosentyx) coverage policy (EFFECTIVE DATE 9/1/2026).

2026-09-01medication_quantity_limits_updated

IV maintenance dosing and maximum maintenance dose specified for Cosentyx: maintenance 1.75 mg/kg every 4 weeks with a maximum maintenance dose of 300 mg per infusion (not to be implemented until 9/1/26).

2026-09-01initial_iv_dosing_defined

OpenPayer

Secukinumab (Cosentyx) — Coverage Criteria

Sign up for all blue cross blue shield - tennessee policy alerts

OpenPayer

Secukinumab (Cosentyx) — Coverage Criteria

Sign up for all blue cross blue shield - tennessee policy alerts

Coverage and Clinical Criteria

Key Definitions and Thresholds

Codes and Coding Notes

Provider Requirements and Documentation

Step Therapy Requirements

Dosing and Quantity Limits

Site of Care and Administration

Background

Revision History