CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Cosentyx (secukinumab) — Coverage Criteria

Defines medical necessity, authorization, continuation, dosing, and quantity limits for Cosentyx (secukinumab) for FDA‑approved indications for members of Neighborhood Health Plan of Rhode Island (Medicaid scope noted). Applies to prescribers and reviewers processing prior authorization requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCosentyx (secukinumab) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date2/2020

Next Review DateN/A

Key ActionSubmit prior authorization with member chart documenting medical necessity, baseline severity, TB screening, vaccination status, and trials of prior therapies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2/2020Effective date

07/2025Most recent review

6 monthsInitial auth (most indications)

12 monthsContinuation auth (many indications)

2 pens/boxFormulary packaging

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Coverage Criteria for Cosentyx (secukinumab)

Initial Therapy — Covered when ALL of the following general requirements AND the indication-specific criteria are met

Covered when ALL of the following general requirements AND the indication‑specific criteria are met

General requirements: Submission of the member's chart/medical record documenting medical necessity; pretreatment TB screening with TB skin test or interferon gamma release assay (unless exempt because of prior biologic/targeted DMARD use); baseline disease severity assessment using an objective measure/tool; patient up to date with age-appropriate vaccinations; no concurrent live vaccines; no active infection; Cosentyx will not be used concomitantly with other injectable biologic response modifiers or specified targeted agents

General prerequisites apply to all indications

FDA-approved indications: Member has one of the listed indications: moderate to severe plaque psoriasis, active psoriatic arthritis, active ankylosing spondylitis, active non-radiographic axial spondyloarthritis, active enthesitis-related arthritis, or moderate to severe hidradenitis suppurativa

Indication-specific criteria follow

Psoriasis (age >=6): Prescribed by or in consultation with a dermatologist or rheumatologist; BSA >= 10% affected OR involvement of crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); and documentation of either (a) inadequate response or intolerance to >=3 months of methotrexate, cyclosporine, or acitretin OR (b) inadequate response or intolerance to >=3 months of phototherapy unless intolerant; inadequate response/intolerance to Zoryve cream within 12 months (unless BSA >20%); and inadequate response, intolerance, or contraindication to >=3 months adalimumab and >=6 months ustekinumab biosimilar at maximum tolerated doses