Cigna Cosentyx Prior Auth Policy Update

Coverage Criteria and Indications

Ankylosing Spondylitis (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following (A or B):

A Initial Therapy: Approve for 6 months if BOTH: i. Patient is >= 18 years of age; AND ii. The medication is prescribed by or in consultation with a rheumatologist6 months

B Ongoing Therapy: Approve for 1 year if BOTH: i. Patient has been established on Cosentyx subcutaneous or intravenous for at least 6 months; AND ii. When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline or experienced improvement in at least one symptom (e.g., decreased pain or stiffness, improved function or activities of daily living)1 year

Patients who have received < 6 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Enthesitis‑Related Arthritis (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following (A or B):

A Initial Therapy: Approve for 6 months if BOTH: i. Patient is >= 4 years of age; AND ii. The medication is prescribed by or in consultation with a rheumatologist6 months

B Ongoing Therapy: Approve for 1 year if BOTH: i. Patient has been established on Cosentyx subcutaneous for at least 6 months; AND ii. When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline or experienced improvement in at least one symptom (examples: improved limitation of motion, less joint pain or tenderness, decreased duration of morning stiffness or fatigue, improved function)1 year

Patients who have received < 6 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Hidradenitis Suppurativa (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following criteria (A or B):

A Initial Therapy: Approve for 3 months if ALL: i. Patient is >= 18 years of age; AND ii. Patient has tried at least one other therapy (examples: intralesional or oral corticosteroids, systemic antibiotics, isotretinoin); AND iii. The medication is prescribed by or in consultation with a dermatologist3 months

B Ongoing Therapy: Approve for 1 year if ALL: i. Patient has been established on Cosentyx subcutaneous for at least 3 months; AND ii. When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline (examples: Hurley staging, Sartorius score, Physician Global Assessment, Hidradenitis Suppurativa Severity Index); AND iii. Compared with baseline, patient experienced improvement in at least one symptom (e.g., decreased pain or drainage of lesions, nodules, or cysts)1 year

Patients who have received < 3 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Non‑Radiographic Axial Spondyloarthritis (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following (A or B):

A Initial Therapy: Approve for 6 months if ALL: i. Patient is >= 18 years of age; AND ii. Patient has objective signs of inflammation defined as at least ONE of: (a) C-reactive protein elevated beyond the upper limit of normal for the reporting laboratory; OR (b) sacroiliitis reported on magnetic resonance imaging; AND iii. The medication is prescribed by or in consultation with a rheumatologist6 months

Patients who have received < 6 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Plaque Psoriasis (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following (A or B):

A Initial Therapy: Approve for 3 months if ALL: i. Patient is >= 6 years of age; AND ii. Patient meets ONE of the following: (a) Patient has tried at least one traditional systemic agent for psoriasis for at least 3 months unless intolerant; OR (b) According to the prescriber, the patient has a contraindication to methotrexate; AND iii. The medication is prescribed by or in consultation with a dermatologist3 months

An exception to the requirement for a trial of one traditional systemic agent is allowed if the patient has had a 3-month trial or prior intolerance to at least one biologic (other than Cosentyx), Otezla/Otezla XR (apremilast), or Sotyktu (deucravacitinib); biosimilars of Cosentyx do not count

B Ongoing Therapy: Approve for 1 year if ALL: i. Patient has been established on Cosentyx subcutaneous for at least 3 months; AND ii. Patient experienced a beneficial clinical response defined as improvement from baseline in at least one of: estimated body surface area, erythema, induration/thickness, and/or scale; AND iii. Compared with baseline, patient experienced improvement in at least one symptom (e.g., decreased pain, itching, or burning)1 year

Patients who have received < 3 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Psoriatic Arthritis (FDA‑approved)

Approve for the duration noted if the patient meets ONE of the following (A or B):

A Initial Therapy: Approve for 6 months if BOTH: i. Patient is >= 2 years of age; AND ii. The medication is prescribed by or in consultation with a rheumatologist or a dermatologist6 months

B Ongoing Therapy: Approve for 1 year if BOTH: i. Patient has been established on Cosentyx subcutaneous or intravenous for at least 6 months; AND ii. Patient experienced benefit by at least one objective measure or symptom improvement compared with baseline (examples: DAPSA, CPDAI, PsA DAS, MDA, enthesitis/dactylitis scores, CRP/ESR)1 year

Patients who have received < 6 months of therapy or who are restarting therapy are reviewed under Initial Therapy

Highlighted coverage criteria and non‑coverage

Key coverage stances and criteria updates present in this document excerpt

Plaque Psoriasis Initial Therapy Exception: Patient must have trialed one traditional systemic agent OR meet an allowed exception: a 3-month trial or prior intolerance to Otezla/Otezla XR (apremilast) or Sotyktu (deucravacitinib)3 months

Biosimilars of Cosentyx do not count toward exceptions

Methotrexate Contraindication Documentation: When relying on a methotrexate contraindication for initial therapy, the prescriber must state that the patient has a contraindication to methotrexate ('according to the prescriber')

Wording changed in revision history

Uveitis: Efficacy of Cosentyx is not established for uveitis; three Phase III studies did not show a statistically significant difference versus placebo

Requests for uveitis indication are unsupported by the cited trial evidence

Use of Cosentyx subcutaneous for any indication not listed in the FDA‑approved indications is considered not medically necessary. The policy explicitly lists off‑label or other uses as not covered and states the list is not all‑inclusive; criteria will be updated as new published data become available.

Concurrent administration of Cosentyx with another biologic or with a targeted synthetic oral small molecule drug for an inflammatory condition is not covered. Combination therapy is discouraged due to a potentially higher rate of adverse events and lack of controlled clinical data demonstrating additive efficacy.

The policy identifies specific conditions for which Cosentyx subcutaneous is considered not medically necessary due to insufficient efficacy or safety concerns. These include Crohn's disease (clinical trials showed exacerbations and an early terminated Phase II IV study failed to meet efficacy), rheumatoid arthritis (published studies demonstrated limited or inconsistent benefit compared with available therapies), and uveitis (no established efficacy in Phase III trials).

Use of Cosentyx for uveitis is not supported by trial evidence and is therefore excluded for established efficacy. Three randomized Phase III studies (Behcet's and non‑Behcet's subtypes) did not show a statistically significant difference between Cosentyx subcutaneous and placebo.

Based on available trial data, Cosentyx subcutaneous is considered not medically necessary for Crohn's disease, rheumatoid arthritis, and uveitis. Reported Crohn's disease trials included exacerbations and lack of benefit; rheumatoid arthritis studies showed limited or inconsistent superiority to existing treatments; and Phase III uveitis trials failed to demonstrate statistical benefit versus placebo.

Treatment of noninfectious uveitis — including Behcet's and non‑Behcet's subtypes — with Cosentyx is considered not medically necessary because the cited Phase III trials did not demonstrate a statistically significant benefit compared with placebo.

Coding and Age Thresholds

Coding guidance (referenced)mixed

affected codes

Policy references that claims must be submitted with appropriate covered diagnosis and/or procedure codes; specific billing codes listed elsewhere in full policy.

Age thresholds by indication

Ankylosing spondylitis / Non-radiographic axial spondyloarthritis (adults)Age ≥18 years

Plaque psoriasisAge ≥6 years

Psoriatic arthritisAge ≥2 years

Enthesitis-related arthritisAge ≥4 years

Hidradenitis suppurativaAge ≥18 years

Provider Requirements, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cosentyx subcutaneous. Initial and continuation approvals have specific duration requirements and clinical criteria; initial approval requires the medication to be prescribed by or in consultation with a specialist who treats the condition (e.g., rheumatologist, dermatologist). Use of preferred products is required prior to approval per the referenced Inflammatory Conditions Preferred Specialty Management Policy.

Prior authorization required for Cosentyx subcutaneous (see specific FDA‑approved indication criteria for duration and qualifying requirements).
Initial prescriber/specialist requirement: must be prescribed by or in consultation with a physician who specializes in the condition being treated.
Preferred product requirement: must meet Inflammatory Conditions Preferred Specialty Management Policy (PSM001 or PSM017) requirements prior to approval.

Step Therapy

Step Therapy for Plaque Psoriasis

Step therapy is required for plaque psoriasis initial therapy: a prior trial of at least one traditional systemic agent (e.g., methotrexate, cyclosporine, acitretin) or a 3‑month trial of PUVA is required before approval unless an allowed exception applies. A biosimilar of Cosentyx does not satisfy the step requirement. A patient who has already tried an eligible biologic (other than Cosentyx), Otezla/Otezla XR, or Sotyktu is not required to step back to a traditional systemic agent.

Background and Scope

Cosentyx (secukinumab) is an interleukin‑17A (IL‑17A) antagonist approved for multiple inflammatory conditions, including plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, enthesitis‑related juvenile arthritis, and hidradenitis suppurativa. Guideline recommendations vary by condition; IL‑17 inhibitors are used in specific scenarios such as TNF inhibitor primary nonresponse or contraindication.

Definitions and Clinical Measures

Objective signs of inflammation

DefinitionObjective signs of inflammation include elevated C-reactive protein above the laboratory upper limit of normal and/or sacroiliitis reported on magnetic resonance imaging (MRI).

ContextIn the pivotal trial for non-radiographic axial spondyloarthritis, patients were required to have these objective signs of inflammation to qualify for therapy.

Examples of evidenceLaboratory report showing CRP > ULN; MRI radiology report documenting sacroiliitis.

ACR response criteria

ACR response measuresAmerican College of Rheumatology (ACR) 20/50/70 — standardized composite endpoints measuring 20%, 50%, and 70% improvement in RA signs and symptoms.

Trial contextACR outcomes reported in Cosentyx studies (e.g., Week 16 ACR20 and Week 52 ACR50/70 results) but did not achieve statistical significance for some RA endpoints.

Revision History and Policy Changes

2026-01-01Annual revisionLatest

Plaque psoriasis initial therapy exceptions added: a 3-month trial or prior intolerance to Otezla/Otezla XR (apremilast) or Sotyktu (deucravacitinib) may substitute for one traditional systemic agent; methotrexate contraindication wording changed to 'according to the prescriber, the patient has a contraindication to methotrexate'.

2025-02-01Selected revision

Updated Preferred Specialty Management Policy note (referenced in revision details).

2024-11-01

OpenPayer

Cosentyx Subcutaneous Prior Authorization Policy

Coverage Criteria and Indications

Coding and Age Thresholds

Provider Requirements, Prior Authorization, and Step Therapy

Background and Scope

Definitions and Clinical Measures

Revision History and Policy Changes