CurrentCignaPolicy PSM009

Inflammatory Conditions - Cosentyx Intravenous Preferred Specialty Management

Defines Cigna's Preferred Specialty Management program requirements and non-preferred product exception criteria for Cosentyx intravenous when requested under the prescription drug benefit for ankylosing spondylitis, non-radiographic axial spondyloarthritis, and psoriatic arthritis.

Policy Summary

PayerCigna

PolicyInflammatory Conditions - Cosentyx Intravenous Preferred Specialty Management

Policy CodePolicy PSM009

Change TypeMaterial revisions to preferred product lists and revision history updates

Effective Date09/01/2025

Next Review DateN/A

Key ActionObtain prior authorization and provide documentation of required trials of preferred agents when requesting Cosentyx IV as a non-preferred product.

SourceLink

POLICY UPDATE CHANGES

New policy created and effective 11/01/2024 with subsequent edits through 04/15/2025 and effective date 09/01/2025.

Preferred product lists were updated: selected adalimumab and ustekinumab product examples were added or removed and certain NDC-based preferred designations were removed.

3indications listed

6 monthsinitial approval

1 yearcontinuation approval

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Coverage Criteria for Cosentyx Intravenous

Initial Therapy — Ankylosing Spondylitis

Cosentyx intravenous is considered medically necessary when the non-preferred product exception criteria below are met (applies when Cosentyx IV is requested under the prescription drug benefit).

Ankylosing Spondylitis - Initial Therapy: Approve for 6 months if BOTH (i) patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria; AND (ii) patient has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR (documentation required).2 trials

A trial of multiple adalimumab products counts as ONE product; a trial of either or both Xeljanz products collectively counts as ONE product. Trials of Cimzia, an infliximab product (e.g., Remicade, biosimilars), or Simponi (Aria or subcutaneous) also count toward a trial. Documentation required.

Initial Therapy — nr-axSpA

Non-Radiographic Axial Spondyloarthritis (nr-axSpA) - Initial Therapy: Approve for 6 months if BOTH (i) patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria; AND (ii) patient has tried TWO of Cimzia, Taltz, and Rinvoq (documentation required).2 trials

A trial of Enbrel, an adalimumab product, an infliximab product (e.g., Remicade, biosimilars), or Simponi also counts. A trial of multiple adalimumab products counts as ONE product. Documentation required.

Initial Therapy — Psoriatic Arthritis

Psoriatic Arthritis - Initial Therapy: Approve for 6 months if BOTH (i) patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria; AND (ii) patient has tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya, and Xeljanz/XR (documentation required).2 trials

A trial of multiple adalimumab products counts as ONE product; a trial of multiple ustekinumab products counts as ONE product. Trials of Cimzia, an infliximab product (e.g., Remicade, biosimilars), or Simponi also count toward a TNFi trial. Documentation required.

Continuation Therapy — Patients currently on Cosentyx (SC or IV)

Patients currently receiving Cosentyx (SC or IV)

Current Cosentyx Recipients: Approve for 1 year if BOTH (i) patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria; AND (ii) patient meets ONE of the following: (a) Ankylosing Spondylitis with prior trials of TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR (documentation required); OR (b) nr-axSpA with prior trials of TWO of Cimzia, Taltz, and Rinvoq (documentation required); OR (c) Psoriatic Arthritis with prior trials of TWO qualifying agents per the PsA initial therapy list (documentation required); OR (d) prescriber documents patient has been established on Cosentyx (IV or SC) for at least 90 days.varies (2 trials or established 90 days)

Documentation required for prior trials; a trial of multiple adalimumab or ustekinumab products counts as ONE product; trials of Cimzia, infliximab products, or Simponi may count as noted. Documentation required for established therapy option.

Receipt of a sample of Cosentyx (secukinumab) intravenous or subcutaneous does not satisfy any policy criteria for coverage; samples cannot be used as documentation of a prior trial or established therapy for the purposes of meeting the non-preferred product exception criteria.

Cosentyx intravenous is a Step 2 Non-Preferred product under the Inflammatory Conditions Preferred Specialty Management program and is covered only when the specific non-preferred product exception criteria listed in this policy are met. Any exception other than the listed non-preferred product exception criteria is considered not medically necessary and will not be approved.

Policy Identifiers, Approval Durations, and Codes

Policy Identifiermixed

PSM009

Coverage Policy Number (policy identifier)

inv-08: Initial approval duration — Key facts

Initial approval durationApprove for 6 months for initial therapy when non-preferred product exception criteria are met.

Applies toInitial approvals for Ankylosing Spondylitis, nr-axSpA, and Psoriatic Arthritis per non-preferred product exception criteria.

DocumentationPrescriber must provide documentation of prior trials when required (chart notes, prescription claims, receipts).

inv-09: Continuation approval duration for current Cosentyx recipients — Key facts

Continuation approval durationApprove for 1 year for patients currently receiving Cosentyx (SC or IV).

EligibilityPatient must meet the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria and meet one of the continuation criteria (two prior Step 1 trials per indication or established on Cosentyx ≥90 days).

Provider Requirements and Billing Rules

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Cosentyx Intravenous is subject to the Inflammatory Conditions prior authorization program. The prescriber must follow the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria before approval will be granted.

Step Therapy

Step Therapy (Two Step 1 Trials Required)

Step therapy is required. Approval of Cosentyx Intravenous as a non-preferred product generally requires documented trials of TWO Step 1 Preferred Products from the Rheumatology list (e.g., Enbrel, an adalimumab product, Rinvoq, Taltz, Xeljanz/XR) unless otherwise specified.

Required trials: TWO Step 1 Preferred Products (examples include Enbrel; an adalimumab product such as Humira or biosimilars; Rinvoq; Taltz; Xeljanz/XR).
A trial of multiple adalimumab products counts as ONE Preferred Product; Xeljanz and Xeljanz XR collectively count as ONE product.

Background

Cosentyx intravenous (secukinumab) is an interleukin-17A antagonist indicated for adults with active psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis. This policy applies when Cosentyx IV is requested under the prescription drug benefit and is part of a Preferred Specialty Management program designed to encourage use of Preferred Products before non-preferred agents. Cosentyx IV is designated as a Step 2 Non-Preferred product and, when non-preferred, requires meeting the program’s exception criteria (including documentation of prior trials of Preferred Products) or other qualifying conditions described in the non-preferred product exception criteria.

Definitions and Product Designations

inv-15: Preferred Product — Key facts

Preferred Product designationStep 1 Preferred Products are designated by indication (examples: Adalimumab products, Enbrel, Rinvoq, Taltz, Xeljanz/XR for Ankylosing Spondylitis; Cimzia, Rinvoq, Taltz for nr-axSpA; Adalimumab products, Enbrel, Otezla, Rinvoq/Rinvoq LQ, Skyrizi SC, ustekinumab SC products, Taltz, Tremfya, Xeljanz/XR for Psoriatic Arthritis).

PurposePreferred Products are Step 1 agents used before approval of Step 2 non-preferred products under the Preferred Specialty Management program.

Trial countingA trial of multiple adalimumab products counts as ONE Preferred Product; likewise for multiple ustekinumab products; Xeljanz formulations collectively count as ONE product.

inv-16: Non-Preferred Product Exception Criteria — Summary

Exception criteria summaryCosentyx Intravenous (Step 2 non-preferred) may be approved when the patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization criteria AND has met the specified non-preferred product exception criteria (typically trials of TWO Step 1 Preferred Products per indication, with documentation).

Revision History and Policy Changes

2025-09-01policy_effective_dateLatest

Policy effective date set to 09/01/2025 (policy remains in force until updated or retired).

2025-04-15preferred_product_updates

Added multiple ustekinumab subcutaneous products as Preferred and clarified that trials of multiple ustekinumab products count as one; examples of ustekinumab products were expanded (Stelara, Wezlana, Otufli, Pyzchiva, ustekinumab-ttwe, Selarsdi, Steqeyma, Yesintek, and others).

2025-01-01