CurrentCignaPolicy N/A

Cosentyx (secukinumab) subcutaneous drug quantity management

Defines quantity limits, overrides, and coverage criteria for Cosentyx subcutaneous formulations for Cigna-administered health benefit plans; affects prescribers, pharmacies, and prior authorization reviewers.

Policy Summary

PayerCigna

PolicyCosentyx (secukinumab) subcutaneous drug quantity management

Policy CodePolicy N/A

Change TypeQuantity limits and override additions

Effective Date

Next Review Date

Key ActionSubmit prior authorization with prescriber attestation and prior Cosentyx claim history to request quantity overrides or HS escalation.

SourceLink

POLICY UPDATE CHANGES

Added new quantity limit for Cosentyx 300 mg UnoReady pens of 1 pen per 28 days at retail or 3 pens per 84 days at home delivery.

Added override criteria to approve a one-time override for initiation/induction dosing (e.g., 5 pens retail or 7 pens home delivery for certain indications).

Updated criteria to allow additional quantity for hidradenitis suppurativa patients who tried 300 mg Q4W and require 300 mg Q2W.

1 pen/28d300 mg UnoReady (retail)

3 pens/84d300 mg UnoReady (home)

2 mL/28d150 mg formulation (retail)

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Policy Overview & Key Facts

Any request for a quantity above the specified Drug Quantity Limits must meet one of the explicit override criteria detailed in this policy. Any exception to the specified quantity limits not listed in the criteria is considered not medically necessary. Approvals that meet an override are provided for the durations specified in the criteria (typically one year, with one-time approvals for induction provided for 30 days).

Quantity limits are applied separately for retail and home delivery dispensing; if the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the criteria below and documentation requirements (for example, prescriber attestation and prior-claim lookback) must be satisfied to qualify for a one-time or maintenance override.

Requests that exceed the quantity limits but do not fulfill one of the explicit override criteria are considered not medically necessary and will be denied. Requests exceeding the quantity limits that do not meet the listed override criteria are considered not medically necessary.

Prior authorization and Drug Quantity Management rules apply; if the quantity rule is not met at point of service, coverage is determined by the policy criteria and required documentation (e.g., absence of prior Cosentyx claims within the specified lookback and prescriber attestation).

Prior Cosentyx claim lookback — 130 days

Lookback periodAbsence of claims for Cosentyx in the past 130 days

PurposeVerifies eligibility for induction/initiation one-time overrides (e.g., larger initial supply)

Applies toAll Cosentyx formulations when requesting induction/initial dosing overrides

Coverage Criteria by Formulation

Cosentyx 300 mg UnoReady pen criteria

Cosentyx 300 mg/2 mL UnoReady pens — Covered when meeting criteria below

Induction override: If initiating treatment for plaque psoriasis or hidradenitis suppurativa OR requires additional induction dosing for plaque psoriasis or hidradenitis suppurativa, as verified by the absence of claims for Cosentyx in the past 130 days, approve a one-time override for 5 pens (10 mL) at retail or 7 pens (14 mL) at home delivery.absence of claims in past 130 days

One-time approvals are 30 days.

Maintenance/HS escalation

A) Cosentyx is being used to treat hidradenitis suppurativa.
B) The patient has tried a dose of 300 mg once every 4 weeks.

Formulation-Specific Quantity Limits (Retail vs Home Delivery)

Documentation Required

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Quantities are defined separately for retail vs home delivery dispensing. Approvals and limits apply at the point of service and are subject to the coverage criteria and exceptions. Provider action: Required documentation for overrides — when requesting an exception to the quantity limits, providers must submit clinical documentation supporting medical necessity (e.g., diagnosis, prior treatment history, dosing rationale, and any relevant clinical measurements). Failure to provide adequate documentation may result in denial. Provider action: Ensure claims and prior authorization requests indicate whether dispensing is retail or home delivery so the appropriate quantity limit is applied.

Approvals and limits enforced at point of service.
When requesting an exception: include diagnosis, prior therapies, dosing rationale, and supporting clinical notes.
Indicate retail vs home delivery on requests/claims.

Formulations and Billing Codes

Formulations and associated quantity limit entriesNDC | product

300 mg/2 mL UnoReady pen	Cosentyx 300 mg/2 mL UnoReady pen (quantity limits described)
150 mg/mL prefilled syringe	Cosentyx 150 mg/mL prefilled syringe (quantity limits described)
150 mg/mL SensoReady pen	Cosentyx 150 mg/mL SensoReady pen (quantity limits described)
75 mg/0.5 mL prefilled syringe	Cosentyx 75 mg/0.5 mL prefilled syringe (pediatric)

Initiation / Induction Overrides

Initial therapy overrides — Induction / initiation overrides including one-time larger supply when no prior claims in past 130 days

Induction / initiation overrides

300 mg UnoReady induction: One-time override when initiating plaque psoriasis or hidradenitis suppurativa or requiring additional induction dosing: 5 pens (10 mL) at retail or 7 pens (14 mL) at home delivery if there are no claims for Cosentyx in the past 130 days.absence of claims in past 130 days

One-time approvals are 30 days.

150 mg formulation induction: One-time override when initiating ankylosing spondylitis, non-radiographic axial spondyloarthritis, psoriatic arthritis, enthesitis-related arthritis, plaque psoriasis, or hidradenitis suppurativa: approve 5 mL (5 syringes/pens) retail or 7 mL (7 syringes/pens) home delivery for certain indications, or 10 mL retail or 12 mL home delivery for plaque psoriasis/HS as specified, if no claims in past 130 days.absence of claims in past 130 days

One-time approvals are 30 days.

Continuation Therapy and Approval Duration

Continuation therapy duration — Continuation approvals and duration

Continuation approvals and duration

Maintenance approval duration: Approvals are provided for 1 year in duration unless otherwise noted.1 year

Claims submitted for services that are not accompanied by covered code(s) under this coverage policy will be denied as not covered. Benefit plan documents may override policy language; reviewers must always confirm coverage against the member's applicable benefit plan.

Denials for lack of a covered code may affect member cost sharing and access to therapy — providers should submit claims using the most appropriate, covered product code and include required authorization documentation to avoid claim denial.

Prescriber & Pharmacy Responsibilities

Prior Authorization

Prior authorization and Drug Quantity Management apply at point of service

Prior authorization and the Drug Quantity Management (DQM) program apply to Cosentyx; if the DQM quantity rule is not met at point of sale, coverage is determined by the policy criteria and approvals are generally for one year (one‑time approvals are 30 days).

All approvals are provided for 1 year unless otherwise noted; 'One-time' approvals are provided for 30 days.
If the DQM rule is not met at point of service, coverage will be determined by the Criteria below.

Documentation Required

Required prescriber attestation and prior‑claim verification for overrides

To approve quantity overrides, prescribers must attest to the indication and provide evidence of prior Cosentyx claim history when required—specifically absence of Cosentyx claims in the past 130 days for initiation/induction one‑time overrides.

Absence of claims for Cosentyx in the past 130 days must be verified to qualify for one‑time induction/initiation overrides.

Step Therapy Requirements

Step	Requirement	Documentation required	Coverage decision
1	Patient with hidradenitis suppurativa has trialed Cosentyx 300 mg once every 4 weeks and, per prescriber, requires escalation to 300 mg once every 2 weeks (Q2W)	Prescriber attestation confirming prior trial of 300 mg Q4W and that the patient requires 300 mg Q2W; verification of prior Cosentyx claim history as applicable	Covered with criteria

Dosing Terms & Definitions

Dosing terms — Loading dose, Q4W, Q2W

Loading doseAdministration at Weeks 0, 1, 2, 3, and 4 as specified in dosing instructions (e.g., 300 mg or 150 mg loading series)

Q4WOnce every 4 weeks (used as standard maintenance dosing after loading doses)

Q2WOnce every 2 weeks (used for escalation to 300 mg Q2W in hidradenitis suppurativa when required)

Clinical Background

Cosentyx (secukinumab) is an interleukin‑17A (IL‑17A) antagonist indicated for multiple inflammatory conditions including plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non‑radiographic axial spondyloarthritis, enthesitis‑related arthritis, and hidradenitis suppurativa. Dosing varies by indication, age and weight and may include loading (induction) regimens and maintenance dosing every 4 weeks, with increased frequency for some hidradenitis suppurativa patients.

This policy implements a Drug Quantity Management program for Cosentyx to promote safe and effective use and manage premature dose escalation. If the quantity rule is not met at point of service, coverage is determined by the criteria in this policy; standard quantity limits include 1 pen per 28 days (300 mg UnoReady pen, retail) and 3 pens per 84 days (home delivery), with corresponding limits for the 150 mg and 75 mg formulations.

Policy Changes & Revision History

2026-01-07Selected revisionLatest

Updated criteria to allow additional per-period quantities for hidradenitis suppurativa patients who have tried 300 mg Q4W and require 300 mg Q2W (adds HS escalation path).

2024-10-02Annual revision

Added new quantity limits and override criteria for Cosentyx 150 mg/300 mg prefilled syringes (including one-time induction overrides and expanded home delivery quantities).

2023-11-15Selected revision