By Counterforce Health Team in Cosentyx (secukinumab) —

Getting Cosentyx (Secukinumab) Covered by Humana in Texas: Prior Authorization Forms, Appeals, and Success Strategies

Answer Box: Your Fastest Path to Cosentyx Coverage

Cosentyx (secukinumab) requires prior authorization for all Humana plans in Texas. Submit the Texas Standardized Prior Authorization Request Form via fax (1-888-447-3430) or Humana's provider portal. Include your diagnosis with ICD-10 code, prior therapy failures, PASI/BSA scores, and specialist notes. Standard decisions take 7 days for Part D or 30 days for Medicare Advantage. If denied, request peer-to-peer review within 65 days—success rates exceed 80% with proper documentation.

Start today: Verify your plan type and gather your dermatologist's notes documenting psoriasis severity and failed treatments.

Table of Contents

  1. Before You Start: Verify Your Humana Plan
  2. What You Need to Gather
  3. Submit Your Prior Authorization Request
  4. Follow-Up and Timeline Expectations
  5. If You Need More Information
  6. If Your Request Is Denied
  7. Renewal and Re-authorization
  8. Quick Reference Checklist
  9. Frequently Asked Questions

Before You Start: Verify Your Humana Plan

Confirm Your Plan Type

Humana offers different plan types in Texas, each with distinct prior authorization processes:

Plan Type Prior Auth Process Key Details
Medicare Advantage (Part C) Medical benefit PA 30-day standard decisions; 65-day appeal deadline
Medicare Part D Pharmacy benefit PA 7-day standard decisions; specialty pharmacy required
Commercial/Employer Varies by plan Check your specific formulary tier

Action step: Call the member services number on your insurance card or log into your Humana member portal to confirm your plan type.

Check Cosentyx Formulary Status

Cosentyx is typically a non-preferred specialty drug on Humana formularies, requiring step therapy through preferred alternatives first. Use Humana's Prior Authorization Search Tool to verify current status for your specific plan.

What You Need to Gather

Required Clinical Documentation

Diagnosis Information:

  • Primary diagnosis with ICD-10 code (e.g., L40.0 for plaque psoriasis)
  • Disease severity metrics: PASI score and/or body surface area (BSA) percentage
  • Duration of condition (chronic plaque psoriasis ≥6 months preferred)

Prior Treatment History:

  • Complete list of failed topical therapies (corticosteroids, calcipotriene, etc.)
  • Systemic therapy trials and outcomes (methotrexate, cyclosporine, acitretin)
  • Phototherapy attempts, if applicable
  • Previous biologic failures with specific reasons (lack of efficacy, intolerance, contraindications)

Laboratory Results:

  • Tuberculosis screening (chest X-ray, TB blood test) within past 12 months
  • Hepatitis B and C screening
  • Complete blood count and liver function tests
  • HIV testing if clinically indicated

Specialist Requirements

Cosentyx must be prescribed by or in consultation with a dermatologist or rheumatologist. Ensure your specialist's notes include:

  • Justification for systemic therapy candidacy
  • Documentation of moderate-to-severe disease (BSA ≥3-10% or involvement of hands, feet, face, genitals, or nails)
  • Treatment goals and monitoring plan

Submit Your Prior Authorization Request

Use the Texas-Specific Form

Download and complete the Texas Standardized Prior Authorization Request Form for Prescription Drug Benefits (Form 1154TX0815-B). Key sections include:

Section III (Patient Information):

  • Full name, date of birth, gender, address
  • Humana Member ID, Medicaid ID (if applicable)
  • Group number, BIN, PCN, and Rx ID from insurance card

Section V (Drug Information):

  • Drug name: Cosentyx (secukinumab)
  • Strength and formulation
  • Quantity requested and days' supply
  • Duration of therapy
  • Mark whether this is new therapy or continuation

Section IX (Clinical Justification):

  • List all prior medications tried with dates and outcomes
  • Include specific reasons for failure or discontinuation
  • Attach supporting laboratory values with dates

Submission Options

Primary Methods:

  • Fax: 1-888-447-3430 (most reliable for documentation)
  • Phone: 1-866-461-7273 (for expedited requests)
  • Online: Humana provider portal or CoverMyMeds platform
Tip: Always request a fax confirmation receipt and keep all submission documentation for your records.

Follow-Up and Timeline Expectations

Standard Processing Times

Request Type Timeline Notes
Medicare Part D 7 calendar days Specialty drugs; auto-escalates if delayed
Medicare Advantage 30 days (pre-service) Can request expedited (72 hours) if urgent
Commercial plans Varies by state Typically 15-30 days

When to Follow Up

Day 3: Confirm Humana received your submission Day 5: Check processing status via member portal Day 7 (Part D) or Day 15 (MA): Call if no decision received

Sample follow-up script: "I'm calling to check the status of a prior authorization request for Cosentyx submitted on [date]. The reference number is [if available]. Can you provide an update on the timeline?"

If You Need More Information

Humana may request additional documentation before making a decision. Common requests include:

  • Medical necessity letter from your specialist
  • Recent progress notes showing disease activity
  • Photographs documenting skin involvement
  • Quality of life assessments (DLQI scores)
  • Additional laboratory results

Respond promptly to these requests—delays can restart the review clock.

Medical Necessity Letter Checklist

Your dermatologist's letter should address:

  1. Patient's condition: Specific diagnosis, severity, and duration
  2. Prior treatments: Complete history with dates, dosages, and outcomes
  3. Clinical rationale: Why Cosentyx is medically necessary for this patient
  4. Contraindications: Any reasons other treatments aren't appropriate
  5. Monitoring plan: How response will be assessed and safety monitored

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Step therapy not completed Document all prior therapy trials with specific failure reasons
Insufficient severity documentation Submit updated PASI scores, photos, or BSA calculations
Missing specialist consultation Obtain referral to dermatologist or rheumatologist
Incomplete prior authorization form Resubmit with all required sections completed

Appeal Process in Texas

Internal Appeal (First Level):

  • Deadline: 65 days from denial notice for Medicare plans
  • Submission: Humana Appeals Portal or mail to Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512-4546
  • Timeline: 7 days (Part D) or 30 days (Medicare Advantage) for decision

Peer-to-Peer Review: Request through your provider within 3-5 business days of denial. Success rates exceed 85% when clinical documentation supports medical necessity.

External Review (Texas): If internal appeal fails, Texas law provides Independent Review Organization (IRO) review for medical necessity denials. File within 4 months of final internal denial.

From our advocates: We've seen denials overturned when providers submitted updated severity documentation alongside peer-to-peer requests. The key is demonstrating that Cosentyx meets the plan's own medical necessity criteria, not just general treatment guidelines. Success often comes down to thorough documentation of disease impact and prior treatment failures.

Renewal and Re-authorization

When to Start Renewal Process

Begin renewal requests 30-45 days before your current authorization expires. Humana typically approves Cosentyx for 6-12 month periods.

Renewal Documentation

Include evidence of treatment response:

  • Updated PASI scores showing improvement
  • Progress notes documenting clinical response
  • Photographs showing skin improvement
  • Quality of life improvements (patient-reported outcomes)
  • Continued medical necessity if switching wasn't attempted

Quick Reference Checklist

Before Submitting:

  • Confirm plan type and formulary status
  • Complete Texas PA form (all sections)
  • Gather specialist notes with severity documentation
  • Collect prior therapy failure records
  • Obtain recent TB and hepatitis screening
  • Verify prescriber NPI and contact information

After Submitting:

  • Request fax confirmation
  • Set calendar reminders for follow-up
  • Monitor member portal for updates
  • Prepare appeal documentation if needed
  • Schedule renewal 30-45 days before expiration

Frequently Asked Questions

How long does Humana prior authorization take in Texas? Standard timelines are 7 days for Medicare Part D and 30 days for Medicare Advantage. Expedited reviews are available in 72 hours for urgent cases.

What if Cosentyx is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or ineffective for your condition.

Can I get Cosentyx covered without trying other biologics first? Step therapy requirements vary by plan, but exceptions are possible if you have contraindications to preferred agents or documented failures of required therapies.

Does Humana cover Cosentyx for all approved indications? Coverage varies by plan and indication. Psoriasis, psoriatic arthritis, and ankylosing spondylitis are most commonly covered, while newer indications may require additional documentation.

What specialty pharmacy does Humana use for Cosentyx? CenterWell Specialty Pharmacy is Humana's primary specialty pharmacy, offering mail delivery throughout Texas.

Can I appeal a Humana denial in Texas? Yes, Texas provides strong appeal rights including internal appeals (65-day deadline) and external review through Independent Review Organizations for medical necessity disputes.

Getting expert help with insurance appeals: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed arguments. Their platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's own rules, helping patients, clinicians, and pharmacies get prescription drugs approved more efficiently.

For additional support with Humana appeals in Texas, Counterforce Health provides the clinical documentation and payer-specific workflows needed to meet procedural requirements while tracking deadlines and required attachments.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Humana plan and consult your healthcare provider for medical decisions. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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