CurrentCignaPolicy DQM002

Cosentyx Subcutaneous Drug Quantity Management Policy - Per Days

Defines quantity limits, allowed exceptions, and authorization rules for Cosentyx subcutaneous formulations for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyCosentyx Subcutaneous Drug Quantity Management Policy - Per Days

Policy CodePolicy DQM002

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionIf the Drug Quantity Management rule is not met at point of service, submit authorization per the policy criteria to determine coverage; approvals are generally for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yeartypical approval duration

2 mL/28dretail max 300 mg/2 mL

6 mL/84dhome delivery max 300 mg/2 mL

1 mL/28dretail max 150 mg/mL

0.5 mL/28dretail max 75 mg/0.5 mL

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Drug Quantity Limits and Exceptions

Coverage subject to quantity limits; specified one-time and ongoing overrides allowed when criteria are met.

Drug Quantity Limits

300 mg/2 mL UnoReady pen or prefilled syringe limits: Retail maximum per 28 days = 2 mL (1 pen or prefilled syringe); Home delivery maximum per 84 days = 6 mL (3 pens or prefilled syringes).2 mL/28 days; 6 mL/84 days
chunk 10
150 mg/mL pen or prefilled syringe limits: Retail maximum per 28 days = 1 mL (1 pen or prefilled syringe); Home delivery maximum per 84 days = 3 mL (3 pens or prefilled syringes).1 mL/28 days; 3 mL/84 days
chunk 10
75 mg/0.5 mL prefilled syringe limits: Retail maximum per 28 days = 0.5 mL (1 prefilled syringe); Home delivery maximum per 84 days = 1.5 mL (3 prefilled syringes).0.5 mL/28 days; 1.5 mL/84 days
chunks 10,11

inv-02: Allowed Quantity Exceptions (one-time and dosing schedule overrides)

Exceptions are approved as medically necessary only when specific initiation/induction or dosing needs are met and verified by absence of Cosentyx claims in the past 130 days where specified.

300 mg prefilled syringes/UnoReady pens - exceptions: One-time override for initiation or additional induction dosing for plaque psoriasis or hidradenitis suppurativa if no Cosentyx claims in past 130 days: Retail = 10 mL (5 pens/syringes) one-time; Home delivery = 14 mL (7 pens/syringes) one-time. For hidradenitis suppurativa dosing at 300 mg every 2 weeks, approve 4 mL per 28 days (2 pens/syringes) at retail or 12 mL per 84 days (6 pens/syringes) at home delivery.130-day lookback where noted

chunk 12

150 mg prefilled syringes or SensoReady pens - exceptions: If initiating treatment for ankylosing spondylitis, non-radiographic axial spondyloarthritis, psoriatic arthritis, or enthesitis-related arthritis OR require additional induction dosing for those indications as verified by absence of Cosentyx claims in the past 130 days, approve a one-time override: Retail = 5 mL (5 pens/syringes) one-time; Home delivery = 7 mL (7 pens/syringes) one-time. If initiating treatment for plaque psoriasis or hidradenitis suppurativa OR require additional induction dosing for those, as verified by absence of Cosentyx claims in the past 130 days, approve a one-time override: Retail = 10 mL (10 pens/syringes) one-time; Home delivery = 12 mL (12 pens/syringes) one-time.130-day lookback

Any exception not explicitly listed in this policy is considered not medically necessary.

Exceptions to the stated quantity limits that do not meet the specific criteria outlined in this policy are considered not medically necessary.

Initial Therapy and Induction Overrides

inv-11: Initial Therapy and Induction Overrides

Induction/loading-dose regimens vary by indication; one-time override quantities for initiation or additional induction dosing require verification of no Cosentyx claims in the prior 130 days.

Initiation verification: Initiation or additional induction dosing exceptions require verification by absence of claims for Cosentyx in the past 130 days.

Induction/loading-dose regimens and applicable overrides: Provide one-time override quantities per strength based on indication-specific loading regimens (see strength-specific exception nodes). Loading-dose regimens include multiple weekly doses at Weeks 0–4 for indications such as plaque psoriasis and hidradenitis suppurativa (300 mg) and other indications per prescribing information; dosing may vary by age and weight for pediatric patients.

Continuation Therapy

inv-12: Continuation Therapy

Approvals are generally for 1 year; continuation is subject to adherence to quantity limits or documented exception criteria.

Continuation: Continued coverage requires adherence to quantity limits or documentation meeting allowed exception criteria; approvals are provided for up to 1 year unless otherwise noted.

Cosentyx (secukinumab) Quantity Limits

Cosentyx (secukinumab) subcutaneous injection — quantity limits

DrugCosentyx (secukinumab) subcutaneous injection — varies by strength and formulation

300 mg/2 mL UnoReady pen or prefilled syringe — retail limit2 mL per 28 days (1 pen or 1 prefilled syringe)

300 mg/2 mL UnoReady pen or prefilled syringe — home delivery limit6 mL per 84 days (3 pens or 3 prefilled syringes)

150 mg/mL SensoReady pen or prefilled syringe — retail limit1 mL per 28 days (1 pen or 1 prefilled syringe)

75 mg/0.5 mL prefilled syringe — retail limit0.5 mL per 28 days (1 prefilled syringe)

Provider Actions and Billing Requirements

Note

Drug Quantity Management — Coverage Determination

If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the criteria in this policy. All approvals are provided for 1 year in duration unless otherwise noted.

Approval duration: 1 year unless otherwise noted
Drug Quantity Management noncompliance: coverage reviewed per policy criteria

Documentation Required

Submit Appropriate Covered Codes

Providers must submit the appropriate covered diagnosis and procedure codes when requesting services or submitting claims. When billing, use the most appropriate codes as of the effective date of the submission.

Use current and most appropriate codes as of the submission date
Include covered diagnosis and/or procedure codes with requests and claims

Denial Risk

Claims May Be Denied Without Covered Codes

Claims submitted without covered diagnosis or procedure codes, or services billed for conditions not covered under this policy, may be denied or returned. Reimbursement is not allowed for services billed without covered codes under the applicable Coverage Policy.

Claims lacking covered diagnosis/procedure codes may be denied as not covered
Services billed for non-covered conditions under this policy are not reimbursable

Prior Authorization

Provider Action Required When Quantity Limits Not Met

If Drug Quantity Management rules are not met at point of service, follow the approval process and submit all required documentation and covered codes to support coverage. Providers should ensure prior authorization or other required reviews are completed per plan procedures.

Follow approval process when quantity rules not met
Submit required documentation and covered codes to support any requests for coverage

Definitions

Loading dose — definition and typical timing (Weeks 0–4) vs maintenance dosing

DefinitionLoading dose: multiple weekly doses at treatment initiation (Weeks 0–4) as described per indication; maintenance dosing is typically every 4 weeks.

Ankylosing spondylitis example with loading dose150 mg at Weeks 0, 1, 2, 3, and 4, then 150 mg once every 4 weeks (Q4W)

Ankylosing spondylitis example without loading dose150 mg once every 4 weeks (Q4W) as maintenance dosing

PurposeProvides an induction phase to achieve therapeutic drug levels during Weeks 0–4 before transition to maintenance Q4W dosing.

Background

Cosentyx (secukinumab) is an interleukin‑17A (IL‑17A) antagonist administered by subcutaneous injection and indicated for multiple immune‑mediated conditions including plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, enthesitis‑related arthritis, and hidradenitis suppurativa in specified age groups.

Dosing is indication‑specific and may include a loading dose (multiple weekly doses at treatment initiation, e.g., Weeks 0–4) followed by maintenance dosing typically every 4 weeks; the policy’s Drug Quantity Management program sets maximum retail and home‑delivery volumes and defines allowable one‑time and ongoing exceptions tied to these induction and maintenance regimens.