CurrentUnitedHealthcarePolicy IEXD0132.03

Cosentyx (secukinumab) IV injection — Medical Benefit Drug Policy (coverage criteria)

Defines medical necessity criteria, coverage stance, and administrative requirements for Cosentyx (secukinumab) for intravenous injection under UnitedHealthcare Individual Exchange medical benefit plans (not pharmacy benefit). Affects providers requesting medical benefit coverage for IV secukinumab.

Policy Summary

PayerUnitedHealthcare

PolicyCosentyx (secukinumab) IV injection — Medical Benefit Drug Policy

Policy CodePolicy IEXD0132.03

Change TypeRevised — examples of targeted immunomodulators updated

Effective DateMay 1, 2025

Next Review Date

Key ActionObtain prior authorization for IV Cosentyx; approval is issued for 12 months when criteria and required documentation are met.

SourceLink

POLICY UPDATE CHANGES

Updated list of examples of targeted immunomodulators to add Bimzelx (bimekizumab-bkzx) and standardized naming for ustekinumab; removed a reference link.

12 monthsInitial authorization duration

12 monthsContinuation authorization

3Proven indications

3Unproven/excluded conditions

J3247

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.

Coverage Criteria for IV Cosentyx (secukinumab)

Initial Therapy - Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic Arthritis - Initial Therapy: Diagnosis of active psoriatic arthritis; AND (history of failure to a 3 month trial of methotrexate at the maximally indicated dose unless contraindicated or clinically significant adverse effects are experienced OR patient previously treated with a targeted immunomodulator FDA-approved for psoriatic arthritis as documented by claims or medical records (document drug, date, and duration of therapy) [e.g., Cimzia, adalimumab, Simponi, ustekinumab, Tremfya, Xeljanz/Xeljanz XR, Otezla, Skyrizi, Rinvoq, Enbrel, Bimzelx]); AND Cosentyx is initiated and titrated according to US FDA labeled dosing for PsA; AND Patient is not receiving Cosentyx in combination with a targeted immunomodulator; AND Prescribed by or in consultation with a rheumatologist or dermatologist; AND initial authorization will be issued for 12 months.

Examples of targeted immunomodulators listed in policy include Cimzia (certolizumab), adalimumab, Simponi (golimumab), ustekinumab, Tremfya (guselkumab), Xeljanz (tofacitinib), Otezla (apremilast), Skyrizi (risankizumab), Rinvoq (upadacitinib), Enbrel (etanercept), Bimzelx (bimekizumab-bkzx)

Continuation Therapy - Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic Arthritis - Continuation Therapy: Documentation of positive clinical response; AND Cosentyx is initiated and titrated according to US FDA labeled dosing for PsA; AND Patient is not receiving Cosentyx in combination with a targeted immunomodulator; AND authorization will be issued for 12 months.

Initial and Continuation Therapy - Ankylosing Spondylitis / nr-axSpA

Covered when ALL of the following are met

AS/nr-axSpA - Initial Therapy: Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis; AND (history of failure to two NSAIDs at maximally indicated doses each used for at least 4 weeks unless contraindicated or clinically significant adverse effects are experienced OR patient previously treated with a targeted immunomodulator FDA-approved for AS or nr-axSpA as documented by claims or medical records); AND Cosentyx is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; AND Patient is not receiving Cosentyx in combination with a targeted immunomodulator; AND Prescribed by or in consultation with a rheumatologist; AND initial authorization will be issued for 12 months.

Examples of targeted immunomodulators listed include adalimumab, Simponi (golimumab), Rinvoq (upadacitinib), Xeljanz/Xeljanz XR (tofacitinib), Bimzelx (bimekizumab-bkzx)

AS/nr-axSpA - Continuation Therapy: Documentation of positive clinical response; AND Cosentyx is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; AND Patient is not receiving Cosentyx in combination with a targeted immunomodulator; AND authorization will be issued for 12 months.

Cosentyx (secukinumab) for intravenous injection is considered unproven and not medically necessary for the following conditions: plaque psoriasis, enthesitis-related arthritis, and hidradenitis suppurativa.

Use of IV Cosentyx for these indications is not covered under the medical benefit; the policy specifies that Cosentyx delivered by subcutaneous injection is managed through the pharmacy benefit. Requests for IV secukinumab for plaque psoriasis, enthesitis-related arthritis, or hidradenitis suppurativa will be considered unproven and not medically necessary.

Billing and Coding

Applicable HCPCSHCPCS

J3247

Injection, secukinumab, intravenous, 1 mg.

Applicable ICD-10ICD-10

L40.50	Arthropathic psoriasis, unspecified.
L40.51	Distal interphalangeal psoriatic arthropathy.
L40.52	Psoriatic arthritis mutilans.
L40.53	Psoriatic spondylitis.
L40.54	Psoriatic juvenile arthropathy.
L40.59	Other psoriatic arthropathy.
M08.1	Juvenile ankylosing spondylitis.
M45.0	Ankylosing spondylitis of multiple sites in spine.
M45.1	Ankylosing spondylitis of occipito-atlanto-axial region.
M45.2	Ankylosing spondylitis of cervical region.

1–10 of 27

1/3

Methotrexate trial duration for PsA

Required trial duration3 months at the maximally indicated dose

When trial may be waivedIf methotrexate is contraindicated or patient experienced clinically significant adverse effects

Alternative to methotrexate trialPrior treatment with an FDA‑approved targeted immunomodulator for PsA documented by claims or medical records (document drug, date, duration)

NSAID trial requirement for AS/nr-axSpA

NSAID trial requirementFailure of two NSAIDs at maximally indicated doses, each used for at least 4 weeks

When NSAID requirement may be waivedIf NSAIDs are contraindicated or clinically significant adverse effects are experienced

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Cosentyx IV. Initial authorization will be issued for 12 months when clinical criteria are met. Medical records or claims history may be requested to support the request.

Initial authorization period: 12 months
Medical records or claims history may be required to verify diagnosis, prior therapies, dates, and duration

Denial Risk

Triggers for Potential Denial

Denial may be issued if the patient does not meet the indication‑specific entry criteria (e.g., lacks a diagnosis of the treated condition), if required prior therapies are not documented or contraindications are not justified, if Cosentyx is prescribed in combination with another targeted immunomodulator, or if dosing/initiation is not consistent with FDA‑labeled dosing.

Absence of documented diagnosis meeting policy criteria

Background

Cosentyx (secukinumab) is a human monoclonal antibody that targets interleukin‑17A (IL‑17A). IV formulation decisions in this policy reflect evidence extrapolated from subcutaneous formulations and the product’s pharmacologic class; IV secukinumab is addressed here for specific rheumatologic indications where the policy defines coverage criteria and limitations.

Definitions

Cosentyx (secukinumab) — formulation definitions and benefit distinction

DefinitionCosentyx (secukinumab) is a human interleukin‑17A antagonist monoclonal antibody

IV formulation (medical benefit)Intravenous secukinumab (Cosentyx) is administered as an IV injection and is covered under the medical benefit

Subcutaneous formulation (pharmacy benefit)Secukinumab is also available as a subcutaneous injection formulation, which is covered under the pharmacy benefit

Clinical note on formulationsEffectiveness of IV Cosentyx was extrapolated from subcutaneous formulations based on pharmacokinetic exposure