By Counterforce Health Team in Cosentyx (secukinumab) —

Getting Cosentyx (Secukinumab) Covered by Humana in Ohio: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Fast Track to Cosentyx Approval

Cosentyx requires prior authorization from Humana in Ohio and is covered as a Tier 5 specialty drug. Your fastest path: (1) Have your prescriber submit a complete PA request with medical necessity documentation, including failed step therapy attempts, (2) Ensure the prescription goes to CenterWell Specialty Pharmacy or another Humana-approved specialty pharmacy, and (3) If denied, file an appeal within 65 days using Humana's member portal or by calling 1-800-HUMANA. Start today by calling your prescriber to begin the PA process and verify your plan's specific formulary requirements at Humana's drug list tool.

Table of Contents

Understanding Your Humana Coverage

Cosentyx (secukinumab) is covered on most Humana Medicare Advantage plans in Ohio as a Tier 5 specialty drug, which means higher copayments but guaranteed access once approved. The medication requires special handling due to refrigeration needs and its high cost—typically over $6,000 per month without insurance.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Humana formulary documents Humana Drug Lists
Formulary Tier Tier 5 (Specialty) Plan formulary Humana Medicare Formulary
Step Therapy May require trying preferred alternatives first PA criteria Prior Authorization Resources
Specialty Pharmacy Must use designated specialty pharmacies Network directory CenterWell Specialty
Appeals Deadline 65 days from denial Member handbook Exceptions & Appeals

What Drives Cosentyx Costs

Understanding how Humana structures specialty drug costs helps you plan and advocate effectively:

Tier 5 Specialty Pricing: As a specialty biologic, Cosentyx typically carries 25-33% coinsurance rather than a flat copay. This can mean $1,500-2,000 per month out-of-pocket before reaching your plan's catastrophic coverage threshold.

Prior Authorization Impact: Without PA approval, you'll pay full retail price. The authorization process ensures medical necessity and appropriate use, but creates a coverage barrier that requires proper documentation.

Formulary Placement: Humana may prefer other IL-17 inhibitors like Taltz or require step therapy through TNF inhibitors like Humira before approving Cosentyx.

Investigating Your Benefits

Before starting the approval process, gather this essential information:

Call Humana Member Services (number on your ID card) and ask:

  • "Is Cosentyx on my plan's formulary, and what tier?"
  • "What's my specialty drug copay or coinsurance?"
  • "Do I need prior authorization for Cosentyx?"
  • "Are there step therapy requirements?"
  • "Which specialty pharmacies are in-network?"

Document everything: Record the representative's name, date, and reference number for future appeals.

Tip: If you get conflicting information, ask for the conversation to be noted in your file and request written confirmation.

Prior Authorization Requirements

Your prescriber must submit a comprehensive PA request demonstrating medical necessity. Here's what Humana typically requires:

Medical Necessity Documentation:

  • Confirmed diagnosis with appropriate ICD-10 codes (psoriasis: L40.x, psoriatic arthritis: L40.5x, ankylosing spondylitis: M45.x)
  • Disease severity documentation (PASI scores for psoriasis, joint involvement for PsA)
  • Complete trial history of preferred alternatives and reasons for discontinuation
  • Current medications and contraindications to step therapy options
  • Treatment goals and expected outcomes

Step Therapy Documentation: Most Humana plans require trying preferred agents first, typically including:

  • TNF inhibitors (Humira, Enbrel, or Remicade)
  • Other preferred IL-17 inhibitors if applicable
  • Documentation of inadequate response or intolerance

Timeline: Humana has 72 hours for standard PA decisions and 24 hours for expedited requests when delay could jeopardize your health.

Assistance Options

Multiple programs can reduce your Cosentyx costs:

Cosentyx Connect Program (Commercial Insurance Only):

  • Up to $16,000 annually toward medication costs
  • Additional $1,950 annually for infusion administration
  • Free medication for up to 2 years while appealing insurance denials
  • Enrollment: COSENTYX Connect or 1-844-COSENTYX

Important: This program is NOT available for Medicare, Medicaid, or other government insurance beneficiaries.

Novartis Patient Assistance Foundation (Medicare/Medicaid Eligible):

  • Free medication for qualifying low-income patients
  • Income limits: $90,360 for single person in 2024 (higher in Alaska/Hawaii)
  • Requires tax return documentation
  • Apply at PAP.Novartis.com or call 1-800-277-2254

State Resources in Ohio:

  • Ohio Department of Insurance consumer assistance: 1-800-686-1526
  • OSHIIP (Ohio Senior Health Insurance Information Program) for Medicare questions

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific plan's policies and crafting evidence-based rebuttals. Their platform can help identify the exact denial reasons and generate targeted medical necessity letters that align with Humana's requirements.

Requesting Tiering Exceptions

If Cosentyx isn't covered or is placed on a higher tier than you can afford, request a formulary or tiering exception:

When to Request:

  • Cosentyx isn't on your plan's formulary
  • You need coverage at a lower copay tier
  • Step therapy requirements create unsafe delays

Required Documentation:

  • Prescriber statement explaining why covered alternatives are inappropriate
  • Clinical evidence supporting Cosentyx as the most effective option
  • Documentation of adverse effects or contraindications to preferred drugs

Timeline: 72 hours for standard requests, 24 hours for expedited review.

Specialty Pharmacy Requirements

Humana requires Cosentyx to be dispensed through specialty pharmacies due to storage and handling requirements:

Primary Option: CenterWell Specialty Pharmacy (Humana's preferred specialty pharmacy)

  • Mail-order delivery with temperature monitoring
  • Clinical support and injection training
  • Insurance coordination and PA assistance

Alternative In-Network Specialty Pharmacies: Check Humana's provider directory for other approved options in Ohio.

Retail Pharmacy Limitation: Traditional retail pharmacies generally cannot dispense Cosentyx unless specifically designated as specialty providers in Humana's network.

Coordination Tips:

  • Ensure your prescriber sends prescriptions directly to the specialty pharmacy
  • Expect a call from the pharmacy to coordinate delivery and provide injection training
  • Plan for 7-10 business days for initial prescription processing

Appeals Process in Ohio

If your initial PA request is denied, Ohio provides multiple appeal levels:

Level 1: Internal Appeal (Redetermination)

  • Deadline: 65 days from denial notice
  • Timeline: Humana has 30 days for standard appeals, 72 hours for expedited
  • How to File: Online through MyHumana, by phone, or written request
  • Required: Copy of denial letter, additional medical records, prescriber statement

Level 2: Independent Review

  • Deadline: 65 days from Level 1 denial
  • Timeline: 30 days for standard, 72 hours for expedited
  • Process: Independent medical reviewers evaluate your case

Level 3: Ohio External Review

  • Deadline: 180 days from final insurer denial
  • Process: Ohio Department of Insurance assigns Independent Review Organization (IRO)
  • Timeline: 30 days standard, 72 hours expedited
  • Binding: Decision is binding on Humana if overturned
Note: Self-funded employer plans follow federal ERISA rules rather than Ohio's external review process.

Ohio Department of Insurance Contact:

Planning for Annual Renewals

Plan changes can affect your Cosentyx coverage:

Annual Review Checklist:

  • Verify Cosentyx remains on your plan's formulary
  • Check for tier changes that could increase costs
  • Review PA requirements for any new restrictions
  • Confirm your specialty pharmacy remains in-network
  • Update income documentation for assistance programs

Budget Planning: Factor in potential out-of-pocket costs until reaching catastrophic coverage (typically $8,000+ annually for Medicare Part D).

Conversation Scripts

Calling Humana Member Services: "Hi, I need to verify coverage for Cosentyx, spelled C-O-S-E-N-T-Y-X, for [condition]. Can you tell me if it's on my formulary, what tier it's on, and what my copay would be? I also need to know about prior authorization requirements and which specialty pharmacies I can use."

Prescriber Discussion: "I need Cosentyx for my [condition], but Humana requires prior authorization. Can you help me understand what documentation you'll need to submit? I've tried [list previous medications] without success, and I can provide records of those trials."

Pharmacy Coordination: "I have a new Cosentyx prescription that needs to go to a Humana-approved specialty pharmacy. Can you help me transfer this to CenterWell or another in-network specialty pharmacy? I'll also need injection training and delivery coordination."

FAQ

How long does Humana prior authorization take for Cosentyx in Ohio? Standard PA requests: 72 hours. Expedited requests (when delay could harm your health): 24 hours. Processing may take longer if additional documentation is needed.

What if Cosentyx isn't on my Humana formulary? Request a formulary exception with your prescriber's support. You'll need documentation showing why covered alternatives aren't appropriate for your condition.

Can I get expedited appeals in Ohio? Yes, if waiting for standard processing could seriously jeopardize your health or ability to regain function. Your prescriber must support the expedited request.

Does step therapy apply if I failed similar drugs outside Ohio? Yes, if properly documented. Provide complete medical records showing previous treatment failures, including dates, dosing, duration, and reasons for discontinuation.

What happens if I can't afford my Cosentyx copay? Explore the Novartis Patient Assistance Foundation for free medication (Medicare patients) or manufacturer copay assistance (commercial insurance only). Counterforce Health can also help navigate financial assistance options.

How do I file a complaint against Humana in Ohio? Contact the Ohio Department of Insurance at 1-800-686-1526 or file online. Have your policy information, denial letters, and documentation of communication attempts ready.

What's the difference between internal and external appeals? Internal appeals are reviewed by Humana. External appeals in Ohio are reviewed by independent medical experts through the Ohio Department of Insurance. External review decisions are binding on your insurer.

Can my doctor request a peer-to-peer review? Yes, prescribers can request to speak directly with Humana's medical director to discuss your case. This often helps resolve denials based on clinical judgment.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may change. Always verify current information with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals and coverage strategies, consider consulting with healthcare coverage specialists like those at Counterforce Health.

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