Cosentyx (secukinumab) prior authorization — coverage criteria
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Defines prior authorization, initial approval, and reauthorization criteria for Cosentyx (secukinumab) prefilled syringe or Sensoready pen for multiple indications under Colorado Rocky Mountain Health Plans.
No material clinical or coverage changes in this revision.
Coverage Criteria by Indication
Plaque Psoriasis
Covered when ALL of the following are met for plaque psoriasis:
Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response and absence of combination therapy.
Psoriatic Arthritis
Covered when ALL of the following are met for psoriatic arthritis:
Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response and absence of combination therapy.
Ankylosing Spondylitis / Non-radiographic Axial Spondyloarthritis
Covered when ALL of the following are met for ankylosing spondylitis or non-radiographic axial spondyloarthritis:
Authorization will be issued for 12 months; reauthorization requires documentation of positive clinical response and absence of combination therapy.
Enthesitis-Related Arthritis
Covered when ALL of the following are met for enthesitis-related arthritis:
Authorization will be issued for 12 months.
Initial Therapy — Enthesitis-Related Arthritis
Initial Authorization — Enthesitis-Related Arthritis
Authorization will be issued for 12 months.
Reauthorization — Enthesitis-Related Arthritis
Reauthorization — Enthesitis-Related Arthritis
Authorization will be issued for 12 months upon meeting criteria.
Initial Therapy — Hidradenitis Suppurativa (HS)
Initial Authorization — Hidradenitis Suppurativa (HS)
Authorization will be issued for 12 months.
Reauthorization — Hidradenitis Suppurativa (HS)
Reauthorization — Hidradenitis Suppurativa (HS)
Authorization will be issued for 12 months upon meeting criteria.
Use of Cosentyx (secukinumab) in combination with another systemic targeted immunomodulator for the same indication is excluded from approval. The policy explicitly requires that the patient is not receiving Cosentyx in combination with another systemic targeted immunomodulator (examples listed in the policy include agents such as adalimumab, bimekizumab, certolizumab, etanercept, upadacitinib, golimumab, tofacitinib, ixekizumab, risankizumab, guselkumab, ustekinumab, and others) when requesting initial authorization or reauthorization.
Cosentyx must not be used in combination with another systemic targeted immunomodulator for treatment of the same indication. The policy language for initial authorization and reauthorization consistently states that approval requires the patient is not receiving Cosentyx in combination with another systemic targeted immunomodulator, and provides illustrative examples of such agents (e.g., adalimumab, bimekizumab, certolizumab, etanercept, upadacitinib, golimumab, tofacitinib, among others). Requests that include concurrent use for the same indication may be denied.
Initial Authorization Requirements
Initial Therapy — top-level initial authorization requirements by indication
Initial authorization requirements by indication:
Authorization issued for 12 months when criteria met.
Initial Therapy — initial authorization criteria for covered indications
Initial authorization criteria for covered indications
Authorization will be issued for 12 months.
Authorization will be issued for 12 months.
Reauthorization / Continuation Requirements
Reauthorization / Continuation Therapy — general
Reauthorization requirements (continuation therapy):
Authorization issued for 12 months upon meeting criteria.
Continuation Therapy / Reauthorization
Reauthorization requirements for continued Cosentyx coverage
Authorization will be issued for 12 months.
Provider Requirements, Documentation & Denial Triggers
Prior authorization required; diagnosis and combination-therapy check
Prior authorization is required for Cosentyx (secukinumab) prefilled syringe or Sensoready pen; initial approval requires a qualifying diagnosis and that the patient is not receiving Cosentyx in combination with another systemic targeted immunomodulator for the same indication. Authorization will be issued for 12 months.
Initial authorization: diagnosis plus no concurrent systemic targeted immunomodulator
For initial authorization, submit documentation of the specific approved diagnosis (e.g., active enthesitis-related arthritis or moderate to severe hidradenitis suppurativa) and confirm the patient is not receiving Cosentyx in combination with another systemic targeted immunomodulator for the same indication. Authorization will be issued for 12 months when criteria are met.
Step therapy not specified — diagnosis and combination-therapy status govern approval
No explicit step therapy or requirement to fail alternative agents is specified in the presented criteria; the primary prerequisites for approval are a qualifying diagnosis and absence of concurrent systemic targeted immunomodulator therapy for the same indication.
Program-dependent supply limits or step therapy may apply
Supply limits and/or step therapy rules may still apply depending on the program or therapeutic class; verify program-specific limits or automated approval logic prior to authorization submission.
- UnitedHealthcare may approve based on previous claim/medication history, diagnosis codes, and/or claim logic.
- Supply limits and/or Step Therapy may be in place.
Reauthorization documentation: positive response and no combination therapy
For reauthorization, provide documentation of positive clinical response to Cosentyx therapy and confirm the patient is not receiving Cosentyx concomitantly with another systemic targeted immunomodulator for the same indication.
Reauthorization requires documented positive clinical response
Reauthorization will be approved only when documentation shows a positive clinical response to Cosentyx therapy; authorization periods are issued for 12 months upon meeting reauthorization criteria.
Denial risk if diagnosis or criteria do not match approved indications
Requests may be denied if the submitted diagnosis does not match an approved indication (for example, plaque psoriasis, psoriatic arthritis, ankylosing spondylitis/nr-axSpA, enthesitis-related arthritis, or hidradenitis suppurativa) or if other approval criteria are not met.
Combination therapy prohibition — may result in denial
Coverage can be denied if Cosentyx is used in combination with another systemic targeted immunomodulator for treatment of the same indication; confirm no concurrent targeted immunomodulator use at initial request and reauthorization.
- Examples of systemic targeted immunomodulators listed in the policy include adalimumab, certolizumab, etanercept, upadacitinib, golimumab, tofacitinib, and bimekizumab.
Step Therapy and Quantity Limits
| Coverage requirement | Details |
|---|---|
| Diagnosis | |
| - Initial authorization requires diagnosis of the indicated condition (e.g., moderate to severe plaque psoriasis; active psoriatic arthritis; active ankylosing spondylitis or active non‑radiographic axial spondyloarthritis). | |
| Concomitant therapy restriction | |
| - Patient must not be receiving Cosentyx in combination with another systemic targeted immunomodulator for treatment of the same indication (examples listed in policy). | |
| Authorization duration | |
| - Authorization will be issued for 12 months when initial criteria are met. |
| Program note | Implication |
|---|---|
| Automated/program-dependent rules | |
| Notwithstanding coverage criteria, approvals (initial and reauthorization) may be granted based on prior claims/medication history, diagnosis codes (ICD‑10), and/or claim logic; automated approval processes vary by program/therapeutic class. | |
| Supply limits / Step Therapy | |
| Supply limits and/or Step Therapy may be in place depending on program or therapeutic class; specific limits are program‑dependent and not specified in this policy excerpt. |
Key Definitions
Background and Scope
Cosentyx (secukinumab) is a human interleukin-17A antagonist indicated for several immune-mediated inflammatory diseases. Within this policy Cosentyx is addressed for multiple indications (for example, moderate to severe hidradenitis suppurativa is listed explicitly), and approval criteria are organized by indication. Initial authorization requirements typically require a diagnosis of the indicated condition and confirmation that the patient is not receiving Cosentyx in combination with another systemic targeted immunomodulator; when met, authorization is issued for 12 months.
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