CurrentCignaPolicy PSM016

Inflammatory Conditions - Cosentyx Intravenous Preferred Specialty Management for Legacy Drug List Plans

Defines prior authorization and non-preferred product exception criteria for Cosentyx intravenous under Cigna legacy prescription drug lists for ankylosing spondylitis, non-radiographic axial spondyloarthritis (nr-axSpA), and psoriatic arthritis; includes preferred product step therapy requirements and documentation/approval durations.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Cosentyx Intravenous Preferred Specialty Management for Legacy Drug List Plans

Policy CodePolicy PSM016

Change TypeNew and multiple selected revisions (2025-2026)

Effective DateApr 15, 2026

Next Review Date

Key ActionRequests for Cosentyx intravenous must meet the standard Inflammatory Conditions prior authorization and non-preferred product exception criteria with documentation of prior trials.

POLICY UPDATE CHANGES

New policy created (New, Date = 01/01/2025).

For Psoriatic Arthritis: Selarsdi SC, ustekinumab-ttwe SC, and Yesintek SC added as Preferred ustekinumab SC products; note that trials of multiple ustekinumab products count as one product.

Adalimumab-adaz removed as a Preferred Product; Humira clarified to 'NDCs starting with 00074'; adalimumab-ryvk specified as NDCs starting with 82009.

Bimzelx added as a Step 2 agent that counts towards a trial of a Preferred Product.

Imuldosa SC (NDCs starting with 69448) added as a Preferred ustekinumab subcutaneous product.

Otezla XR added for Psoriatic Arthritis as a Step 1 Preferred Product; combination/trial counting rules clarified for Otezla/Otezla XR, Xeljanz products, and Rinvoq products.

3Covered Indications (listed)

6 mo

Coverage Summary

Coverage: Cosentyx intravenous (secukinumab IV) is covered with criteria for adults with active ankylosing spondylitis, non-radiographic axial spondyloarthritis (nr-axSpA), and psoriatic arthritis when prior authorization and the program's step-therapy preferred product requirements are met. The Inflammatory Conditions program directs use of Preferred Products and requires documentation of trials; step therapy and standard prior authorization criteria apply.

Payer/program notes: The program emphasizes use of Step 1 Preferred Products (condition-specific lists) and may accept certain Step 2 agents (e.g., Bimzelx) toward trial requirements. Documentation of prior trials (chart notes, claims, receipts) is required and examples of preferred product NDC prefixes are provided for adalimumab and ustekinumab products.

Approval durations and thresholds: Initial approvals for non-preferred product exceptions are for 6 months when exception criteria are met; continuation approvals (patients currently receiving Cosentyx IV or SC and meeting criteria) are for 1 year. The policy also notes patients must be established on Cosentyx (IV or SC) for at least 90 days to qualify under the continuation pathway.

Initial Therapy Criteria (Non-Preferred Product Exception)

Non-Preferred Product Exception Criteria - Ankylosing Spondylitis (Initial Therapy)

Approve for 6 months if ALL of the following are met:

ALL of the following

Patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria
Patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR

Non-Preferred Product Exception Criteria - Non-Radiographic Axial Spondyloarthritis (nr-axSpA) (Initial Therapy)

Approve for 6 months if ALL of the following are met:

ALL of the following

Patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria
Patient has tried TWO of Cimzia, Taltz, and Rinvoq

Non-Preferred Product Exception Criteria - Psoriatic Arthritis (Initial Therapy)

Approve for 6 months if ALL of the following are met:

ALL of the following

Patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria
Patient has tried TWO of Enbrel, an adalimumab product, Otezla/Otezla XR, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya, and Xeljanz/XR

Continuation Therapy Criteria (Established Patients)

Non-Preferred Product Exception Criteria - Patient Currently Receiving Cosentyx (SC or IV)

Approve for 1 year if ALL of the following are met:

ALL of the following

Patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria
Documentation required. Trials of Cimzia, infliximab products, Simponi, or Bimzelx also count. Multiple adalimumab products count as ONE product.
AND meets ONE of
- Patient has Ankylosing Spondylitis and has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR
  Documentation required. A trial of multiple adalimumab products counts as ONE product. A trial of Cimzia, an infliximab product, Simponi, or Bimzelx also counts.
- Patient has nr-axSpA and has tried TWO of Cimzia, Taltz, and Rinvoq

Step 1 Product Review (when exception criteria not met)

If exception criteria not met - Step 1 Product review

When specific trial count requirements are not met but standard prior authorization criteria are met:

Request for a Step 1 Product may be reviewed using respective standard Inflammatory Conditions - Prior Authorization Policy criteria (lists differ by condition).

Examples by condition provided in policy (Ankylosing Spondylitis: Enbrel, Humira [NDCs starting with 00074], adalimumab-adbm, Cyltezo, adalimumab-ryvk [NDCs starting with 82009], Simlandi, Rinvoq, Taltz, Xeljanz/XR; nr-axSpA: Cimzia, Taltz, Rinvoq; Psoriatic Arthritis: Enbrel, Humira [NDCs starting with 00074], adalimumab-adbm, Cyltezo, adalimumab-ryvk [NDCs starting with 82009], Simlandi, Otezla, Otezla XR, Rinvoq, Rinvoq LQ, Skyrizi SC, Stelara SC, Imuldosa SC [NDCs starting with 69448], Selarsdi SC, ustekinumab-ttwe SC, Yesintek SC, Taltz, Tremfya, Xeljanz/XR).

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Requests for Cosentyx intravenous under the prescription drug benefit must meet the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria and the non-preferred product exception criteria; prior authorization is required and documentation of prior trials is required for exception review.

Requests under the prescription drug benefit must meet both the standard PA criteria and the non-preferred product exception criteria.
Documentation of prior trials is required for exception review.

Documentation Required

Documentation of prior trials

Prescriber must provide written documentation supporting trials of preferred products when documentation is required. Acceptable documentation may include chart notes, prescription claims records, and/or prescription receipts. All documentation must include patient-specific identifying information.

Applicable Codes and Referenced NDCs

Referenced NDCs and product examples (informational for step therapy counting)NDC|mixed

NDCs starting with 00074	Humira (preferred adalimumab product NDC prefix)
NDCs starting with 82009	adalimumab-ryvk (preferred adalimumab product NDC prefix)
NDCs starting with 69448	Imuldosa subcutaneous (preferred ustekinumab SC product NDC prefix)

Definitions & Trial-Counting Rules

Definitions and trial-counting rules: A trial of more than one adalimumab product counts as ONE Preferred Product.

Combined-product families count as a single product for trial purposes; examples explicitly listed include Xeljanz and Xeljanz XR, Otezla and Otezla XR, and Rinvoq and Rinvoq LQ (each pair collectively counts as ONE product).

Additional notes: Trials of multiple ustekinumab products likewise count as ONE product; policy revisions and product-list updates (including addition of Otezla XR and Bimzelx counting rules) are documented in the revision history.

Established on Cosentyxat least 90 days

Approval duration - initial (non-preferred exception)6 months

Approval duration - continuation if currently receiving1 year

Clinical Evidence & References

Evidence and references: The policy cites Cosentyx prescribing information as the primary prescribing reference: Cosentyx prescribing information, Novartis; October 2023.

Policy basis: The Coverage Policy and Inflammatory Conditions program outline clinical indications, step-therapy expectations, documentation requirements, and exception criteria used to determine medical necessity for Cosentyx intravenous for the covered indications.

Revision History

01/01/2025policy_created

New policy created (New, Date = 01/01/2025). Policy marked new in revision history.

(selected revision, date not specified)preferred_list_update

For Psoriatic Arthritis: Selarsdi SC, ustekinumab-ttwe SC, and Yesintek SC added as Preferred ustekinumab subcutaneous products; note that trials of multiple ustekinumab products count as one product.

04/15/2025ndc_and_product_clarification

Adalimumab-adaz removed as a Preferred Product; Humira clarified to 'NDCs starting with 00074'; adalimumab-ryvk specified as NDCs starting with 82009; examples of ustekinumab products updated.