CurrentCignaPolicy PSM016

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

Defines prior authorization, step therapy (preferred product trials), and exception criteria for coverage of Cosentyx intravenous (secukinumab IV) under Cigna legacy prescription drug list plans for ankylosing spondylitis, non-radiographic axial spondyloarthritis, and psoriatic arthritis.

Policy Summary

PayerCigna

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

Policy CodePolicy PSM016

Change TypeMaterial updates to Preferred and Step agent lists

Effective DateJan 1, 2025

Next Review Date

Key ActionObtain prior authorization and document required trials of Preferred (Step 1) and Step 2 agents per the program before requesting Cosentyx IV.

SourceLink

POLICY UPDATE CHANGES

Selsardi subcutaneous, ustekinumab-ttwe subcutaneous, and Yesintek subcutaneous were added as Preferred for Psoriatic Arthritis.

Adalimumab-adaz was removed as a Preferred Product and Humira updated to specify NDCs starting with 00074; adalimumab-aacf was later added to examples.

Bimzelx was added as a Step 2 agent that can count towards a trial of a Preferred Product.

3FDA indications

6 monthsInitial approval

1 yearContinuation approval

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Coverage Criteria for Cosentyx Intravenous

Ankylosing Spondylitis - Initial Therapy

Covered when ALL of the following are met:

Ankylosing Spondylitis initial: (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).two distinct agents from the list; multiple adalimumab products count as ONE; Xeljanz and Xeljanz XR collectively count as ONE

Approve for 6 months if met.

Non-radiographic Axial Spondyloarthritis - Initial Therapy

Covered when ALL of the following are met:

nr-axSpA initial: (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).two distinct agents from the list; other listed agents also may count as noted; multiple adalimumab products count as ONE

Approve for 6 months if met.

Psoriatic Arthritis - Initial Therapy

Covered when ALL of the following are met:

Psoriatic Arthritis initial: (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/Otezla XR, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya, and Xeljanz/XR (documentation required).two distinct agents from the list; multiple adalimumab or ustekinumab products count as ONE; combinations of agents as noted count accordingly

Approve for 6 months if met.

Continuation Therapy / Patients currently receiving Cosentyx

Covered when ALL of the following are met:

Current Cosentyx (SC or IV): (i) Patient meets the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy criteria; AND (ii) patient meets ONE of the following: a) For Ankylosing Spondylitis: has tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR (documentation required); OR b) For nr-axSpA: has tried TWO of Cimzia, Taltz, and Rinvoq (documentation required); OR c) For Psoriatic Arthritis: has tried TWO of Enbrel, an adalimumab product, Otezla/Otezla XR, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya, or Xeljanz/XR (documentation required); OR d) Patient has been established on Cosentyx (intravenous or subcutaneous) for at least 90 days per prescriber.meeting one of the listed alternatives (a-d) or established therapy ≥90 days

Approve for 1 year if met.

Cosentyx intravenous (secukinumab IV) is considered medically necessary only when the specified nonpreferred product exception criteria are met. These exception criteria follow the program’s step-therapy and prior authorization requirements and incorporate rules about counting multiple products in the same biologic family (for example, multiple adalimumab or ustekinumab products count as a single Preferred Product trial).

Any exception request for Cosentyx intravenous that does not meet the stated non-preferred product exception criteria is considered not medically necessary and will not be approved for coverage under this policy.

Coding and Approval Durations

Covered CPT/HCPCS/NDC/ICD codesmixed

No codes listed

Approval duration — initial and continuation approval periods

Initial approval periodApprove initial non-preferred Cosentyx IV requests for 6 months when specified initial-therapy criteria are met.

Continuation approval periodApprovals for continuation of therapy (patients already receiving Cosentyx SC or IV) are provided for 1 year when continuation criteria are met.

Definition of month for initial approvalsWhen initial approval is authorized in months, 1 month is equal to 30 days.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization is required for Cosentyx Intravenous under this program. Providers must obtain authorization in accordance with the standard Prior Authorization Policy before coverage will be considered.

Cosentyx Intravenous requires prior authorization under the Inflammatory Conditions program.
Refer to the Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy for full PA criteria.

Step Therapy

Program Step-Therapy Rules — Trials of Preferred Products Required

The program uses step-therapy requiring trials of Preferred Products before approval of Non-Preferred Products. Trials must follow the Step 1 → Step 2 → Step 3 sequence where applicable; Cosentyx Intravenous is positioned as a Step 3 Non-Preferred product and generally requires trials of Preferred agents first.

Step 1: Trial(s) of Preferred Products (e.g., adalimumab products, Enbrel, Rinvoq, Taltz, etc.) are required when clinically appropriate.

Definitions

Preferred Product trial — definition and examples of Step 1 preferred agents

Preferred Product trial (Step 1) definitionA documented trial of listed Step 1 preferred agents is required prior to approval of non-preferred products; documentation may include chart notes, prescription claims records, or prescription receipts and must include patient identifiers.

Examples of Step 1 preferred agents for rheumatologyExamples include Enbrel (etanercept), adalimumab products (e.g., Humira, Abrilada, adalimumab-aacf, adalimumab-adaz, etc.), Taltz (ixekizumab), and Rinvoq (upadacitinib).

Counting rules for trialsMultiple formulations of the same biologic family (e.g., multiple adalimumab products) count as a single trial; Xeljanz and Xeljanz XR collectively count as one trial.

Where to find full Step 1 lists and program structureRefer to the Inflammatory Conditions Preferred and Non-Preferred Products table and the standard Inflammatory Conditions - Cosentyx Intravenous Prior Authorization Policy for specific product placement and step therapy requirements.

Background

Cosentyx intravenous is secukinumab administered intravenously and is an interleukin-17A (IL-17A) antagonist. It is indicated for adults with active psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis. Coverage decisions for Cosentyx IV under this policy reference the program’s prior authorization and step-therapy structure and the nonpreferred product exception criteria described herein.