CurrentMass General Brigham Health PlanPolicy N/A

Cosentyx (secukinumab) subcutaneous therapy — Clinical prior authorization

Clinical prior authorization policy for Cosentyx (secukinumab) subcutaneous formulations under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members; includes indication-specific medical necessity criteria, continuation, limits, and specialty pharmacy requirement.

Policy Summary

PayerMass General Brigham Health Plan

PolicyCosentyx (secukinumab) subcutaneous therapy — Clinical prior authorization

Policy CodePolicy N/A

Change TypeMaterial and administrative updates

Effective DateMay 1, 2026

Next Review DateMar 11, 2026

Key ActionPrior authorization is required and specialty pharmacy dispensing is mandated for Cosentyx subcutaneous products; submit medical records for members new to the plan (<=90 days).

SourceLink

POLICY UPDATE CHANGES

Policy designates Cosentyx subcutaneous prefilled syringe and auto-injector as pharmacy benefit only and Cosentyx IV as medical benefit only.

Initial approvals for members new to the plan within the past 90 days who are currently receiving treatment will be granted for 3 months.

Administrative update changing verbiage in notes and updating language for members who are new to the Plan.

24 monthsstandard approval duration when criteria met

3 monthsinitial approval for new-to-plan members

1 inj/28d

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Coverage Criteria — Indication-specific and Continuation Rules

Initial therapy — Moderate to severe plaque psoriasis

Covered when ALL of the following are met

plaque_psoriasis_initial: Member has diagnosis of moderate to severe plaque psoriasis

bsa_or_crucial_area: At least 3% of body surface area (BSA) is affected OR crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) are affected

topical_trial_or_severe: Member meets ONE of: (a) minimum 4-week trial and failure, intolerance, or contraindication to ONE topical therapy (corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar) OR (b) severe psoriasis warrants a biologic DMARD as first-line

preferred_biologic_trials: Trial and failure, intolerance, or contraindication to TWO of the following: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, or Yuflyma; Otezla/Otezla XR; Skyrizi; Sotyktu; Selarsdi, Steqeyma, or Yesintek; Tremfya

taltz_bimzelx: Trial and failure, intolerance, or contraindication to BOTH of the following: Taltz AND Bimzelx

Initial therapy — Active psoriatic arthritis (PsA)

Covered when ALL of the following are met

psa_diagnosis: Diagnosis of active psoriatic arthritis (PsA)

two_preferred_biologics: Trial and failure, intolerance, or contraindication to TWO of the following: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, or Yuflyma; Otezla/Otezla XR; Rinvoq/Rinvoq LQ; Simponi; Skyrizi; Selarsdi, Steqeyma, or Yesintek; Tremfya; Xeljanz/Xeljanz XR

taltz_trial: Trial and failure, intolerance, or contraindication to Taltz

one_of_orencia_bimzelx: Trial and failure, intolerance, or contraindication to ONE of the following: Orencia OR Bimzelx

Initial therapy — Ankylosing spondylitis (AS)

Covered when ALL of the following are met

as_diagnosis: Diagnosis of active ankylosing spondylitis

nsaid_trials: Minimum 1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs at maximally tolerated doses

two_biologics: Trial and failure, intolerance, or contraindication to TWO of the following: Cimzia; Enbrel; Humira (Abbvie), Hadlima, Simlandi, or Yuflyma; Rinvoq; Simponi; Xeljanz/Xeljanz XR

taltz_and_bimzelx: Trial and failure, intolerance, or contraindication to BOTH of the following: Taltz AND Bimzelx

Initial therapy — Non-radiographic axial spondyloarthritis (nr-axSpA)

Covered when ALL of the following are met

nraxsp_diagnosis: Diagnosis of active non-radiographic axial spondyloarthritis (nr-axSpA)

objective_inflammation: Objective signs of inflammation (e.g., CRP above the upper limit of normal and/or sacroiliitis on MRI)

nsaid_trials_nraxsp: Minimum 1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs at maximally tolerated doses

required_biologics: Trial and failure, intolerance, or contraindication to ALL of the following: Cimzia; Rinvoq; Taltz; Bimzelx

Initial therapy — Moderate to severe hidradenitis suppurativa (HS)

Covered when ALL of the following are met

hs_diagnosis: Member has a diagnosis of moderate to severe hidradenitis suppurativa (Hurley stage II or III)

adalimumab_trial: Trial and failure, intolerance, or contraindication to ONE of the following: Humira (Abbvie); Hadlima; Simlandi; Yuflyma

bimzelx_trial: Trial and failure, intolerance, or contraindication to Bimzelx

Initial therapy — Enthesitis-related arthritis (ERA)

Covered when ALL of the following are met

era_age: Member is 4 years of age or older

era_active: Member has active enthesitis-related arthritis (ERA) (arthritis and enthesitis, arthritis alone, or enthesitis alone)

era_nsaid_trials: Trial and failure, contraindication, or intolerance to at least TWO NSAIDs at maximally tolerated doses

era_exclusion: Exclusion: children with a first-degree relative with psoriasis, positive rheumatoid factor (RF), or systemic arthritis are excluded from this category

Continuation of Therapy (Reauthorization)

Reauthorization granted when ALL of the following are met

meets_initial_prereqs: Member continues to meet the biologic trial requirements listed in the initial criteria for the treated condition

This policy applies to Cosentyx (secukinumab) subcutaneous formulations under the pharmacy benefit only. Cosentyx administered intravenously (Cosentyx IV) is available and billed through the medical benefit. The subcutaneous products are designated as specialty medications and must be dispensed through a contracted specialty pharmacy.

Requests that do not meet the specific diagnostic criteria in this policy, lack required prior trials (including indication‑specific topical, NSAID, or biologic/small molecule trials), or fail to include required supporting documentation may be considered not medically necessary and denied. For members new to the plan (coverage effective ≤ 90 days), submission of medical records documenting that the member is currently receiving the requested drug is required; failure to provide such records is a trigger for denial. Reauthorization requires documentation demonstrating clinical improvement or low disease activity.

Key Clinical Thresholds and Coding-related Values

inv-10: Body Surface Area (BSA) — threshold used in psoriasis criteria

Body Surface Area (BSA) threshold>= 3% of body surface area

Alternative qualifying findingInvolvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Context of useUsed to define 'moderate to severe plaque psoriasis' for coverage of Cosentyx

inv-11: NSAID trial duration and related prior-failure requirements for AS, nr-axSpA, and ERA

AS and nr-axSpA NSAID requirementMinimum 1-month trial and failure, contraindication, or intolerance to TWO different NSAIDs at maximally tolerated doses

ERA NSAID requirementTrial and failure, contraindication, or intolerance to at least TWO NSAIDs at maximally tolerated doses

Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization and Specialty Pharmacy

Prior authorization is required for Cosentyx subcutaneous products when covered under the pharmacy benefit. This medication is designated as specialty and must be dispensed by a contracted specialty pharmacy. Cosentyx IV is available via the medical benefit only; Cosentyx subcutaneous prefilled syringe and auto-injector are pharmacy benefit only.

Program Type: Prior Authorization required
Benefit: Pharmacy Benefit (subcutaneous forms)
Specialty dispensing required at contracted specialty pharmacy
Medical benefit: Cosentyx IV only

Documentation Required

Required Documentation

Authorizations may be granted only when diagnosis-specific required prior trials are documented. For members new to the plan (coverage effective date ≤ 90 days), submit medical records showing the member is currently receiving the requested drug (samples and manufacturer patient assistance program supplies excluded).

Definitions and Background

inv-17: Definition — Moderate to severe plaque psoriasis (BSA >= 3% or involvement of crucial areas)

DefinitionDiagnosis of plaque psoriasis with >= 3% BSA affected OR involvement of crucial body areas (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Crucial body areas listedHands, feet, face, neck, scalp, genitals/groin, intertriginous areas

Age indication contextCosentyx indicated for moderate to severe plaque psoriasis in patients 6 years of age and older

inv-18: Objective signs of inflammation (nr-axSpA) — elevated CRP and/or sacroiliitis on MRI without definitive radiographic damage

Objective signs of inflammation — definitionElevated C-reactive protein (CRP) above the upper limit of normal and/or sacroiliitis on MRI

Radiographic qualifier

Step Therapy

Required Prior Trials

Indication-specific prior trial requirements must be met and documented in the medical record. Authorization criteria include (but are not limited to) the following trial/failure/intolerance/contraindication requirements by diagnosis:

Plaque psoriasis: topical therapy trial (≥4 weeks) OR severe disease warranting biologic first-line; failure/intolerance to two constituent biologics (e.g., Cimzia, Enbrel, Humira family, Otezla, Skyrizi, Sotyktu, Selarsdi/Steqeyma/Yesintek, Tremfya) and failure/intolerance to both Taltz and Bimzelx.
Psoriatic arthritis: failure/intolerance to two biologics (list includes Cimzia, Enbrel, Humira family, Otezla, Rinvoq, Simponi, Skyrizi, Selarsdi/Steqeyma/Yesintek, Tremfya, Xeljanz) and failure/intolerance to Taltz and one of (Orencia or Bimzelx); plus documented active disease features (e.g., inflamed joints, dactylitis, enthesitis, axial disease, active skin/nail involvement).
Ankylosing spondylitis: ≥1 month trial and failure/intolerance/contraindication to two different NSAIDs, failure/intolerance to two biologics (e.g., Cimzia, Enbrel, Humira family, Rinvoq, Simponi, Xeljanz) and failure/intolerance to both Taltz and Bimzelx.
Non-radiographic axial spondyloarthritis: objective signs of inflammation required (e.g., elevated CRP or MRI sacroiliitis), ≥1 month trial and failure/intolerance/contraindication to two NSAIDs, and failure/intolerance to all of Cimzia, Rinvoq, Taltz, and Bimzelx.
Hidradenitis suppurativa: Hurley stage II or III, failure/intolerance/contraindication to one anti-TNF (e.g., Humira family) and failure/intolerance to Bimzelx.
Enthesitis related arthritis (ERA): age ≥4 years, active ERA, trial and failure/intolerance/contraindication to ≥2 NSAIDs at maximally tolerated doses; pediatric exclusions apply (first-degree relative with psoriasis, positive RF, or systemic arthritis).