By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx Covered by Blue Cross Blue Shield in Virginia: Complete 2025 Guide with Forms and Appeal Scripts

Answer Box: Getting Cosentyx Covered in Virginia

Cosentyx (secukinumab) requires prior authorization from Blue Cross Blue Shield Virginia and may face step therapy requirements. Your fastest path to approval: 1) Complete tuberculosis screening and document PASI score ≥10 or significant disease impact, 2) Show failed trials of preferred biologics like Humira or Enbrel, 3) Submit through Anthem's provider portal with comprehensive clinical documentation. If denied, Virginia offers external review through the State Corporation Commission within 120 days. Start by gathering your insurance card, diagnosis records, and prior treatment history.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cosentyx prescriptions Anthem Provider Portal
Step Therapy May require trials of TNF inhibitors first Varies by plan design
PASI Score Documentation Typically need ≥10 or significant impact areas Clinical notes, photos
TB Screening Mandatory baseline screening within 12 months QuantiFERON-TB or PPD results
Formulary Status Specialty tier, non-preferred in many plans Member ID card pharmacy number
Appeals Deadline 120 days for Virginia external review SCC Form 216-A

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Severity (Patient + Provider)

Document your psoriasis or psoriatic arthritis diagnosis with ICD-10 codes. For plaque psoriasis, ensure your PASI score is ≥10 or document significant involvement of sensitive areas (face, genitals, palms). Take photos if possible.

Timeline: Same day as appointment
Documents needed: Clinical notes, PASI assessment, photos

2. Complete Required Screening (Provider)

Your doctor must order and document tuberculosis screening results. This typically includes QuantiFERON-TB Gold or tuberculin skin test within the past 12 months.

Timeline: 1-3 days for lab results
Submit via: Include with PA request

3. Document Prior Treatment Failures (Provider)

Anthem typically requires evidence you've tried and failed at least one preferred biologic like adalimumab (Humira) or etanercept (Enbrel). Document specific medications, dosages, duration, and reasons for discontinuation.

Timeline: Gather from medical records
Key details: Drug names, dates, outcomes, adverse events

4. Submit Prior Authorization Request (Provider)

Your provider submits the PA request through Anthem's provider portal or designated PA form with all supporting documentation.

Timeline: 72 hours for urgent, 7 business days for standard
Required documents: PA form, clinical notes, lab results, photos

5. Follow Up on Decision (Patient + Provider)

Anthem will issue an approval or denial notice. If approved, coordinate with specialty pharmacy for delivery. If denied, immediately request the specific denial reason.

Timeline: Decision within stated timeframes
Next step: Appeal if denied

6. File Appeal if Denied (Provider)

Submit internal appeal with additional clinical rationale, peer-reviewed literature, and any new supporting evidence within plan deadlines.

Timeline: 30 days typically
Enhancement: Request peer-to-peer review

7. Escalate to External Review if Needed (Patient)

If internal appeals fail, file for Virginia external review using SCC Form 216-A within 120 days of final denial.

Timeline: 45 days for standard review
Cost: Free in Virginia

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient PASI score Document disease impact on quality of life, sensitive area involvement Photos, quality of life questionnaires, detailed clinical notes
Missing TB screening Complete and submit screening results QuantiFERON-TB or PPD within 12 months
Step therapy not met Document failed trials of preferred biologics Medication history, adverse event reports, treatment timelines
Lack of medical necessity Provide clinical rationale with guideline citations FDA labeling, dermatology guidelines, peer-reviewed studies
Incomplete documentation Submit comprehensive clinical packet All required forms, notes, labs, photos
From Our Advocates: We've seen cases where patients were initially denied for "insufficient severity" despite significant psoriasis impact. The key was documenting not just PASI scores, but also functional impairment—how the condition affected work, relationships, and daily activities. Photos of affected areas, especially hands and face, can be particularly compelling evidence for reviewers.

Clinician Corner: Medical Necessity Letter Checklist

When drafting your medical necessity letter for Cosentyx, include these essential elements:

Problem Statement:

  • Specific diagnosis with ICD-10 code (L40.0 for plaque psoriasis, L40.50 for psoriatic arthritis)
  • Disease severity markers (PASI score, BSA involvement, functional impact)
  • Current symptoms and their impact on quality of life

Prior Treatment History:

  • Complete list of previous therapies with specific names, dosages, and duration
  • Documented reasons for discontinuation (inadequate response, adverse events, contraindications)
  • Timeline showing progression through treatment options

Clinical Rationale:

  • Why Cosentyx is medically necessary for this specific patient
  • Contraindications or concerns with preferred alternatives
  • Expected treatment goals and monitoring plan

Supporting Evidence:

  • FDA prescribing information for approved indications
  • Relevant clinical guidelines from American Academy of Dermatology or American College of Rheumatology
  • Peer-reviewed studies supporting use in similar cases

Appeals Playbook for Blue Cross Blue Shield Virginia

Internal Appeal Process

Level 1: Standard Internal Appeal

  • Deadline: 30 days from denial notice
  • Timeline: 7 business days for standard, 72 hours for urgent
  • Submit via: Anthem provider portal or member services
  • Required: Appeal form, clinical justification, supporting documents

Level 2: Peer-to-Peer Review

  • When to use: After initial denial, before or during internal appeal
  • Process: Provider speaks directly with Anthem medical director
  • Timeline: Usually scheduled within 1-2 business days
  • Preparation: Have clinical notes, guidelines, and patient history ready

External Review Process

If internal appeals fail, Virginia law provides external review through the State Corporation Commission Bureau of Insurance.

Eligibility Requirements:

  • Completed all internal appeals with your health plan
  • Denial based on medical necessity, experimental treatment, or similar clinical judgment
  • Virginia-issued plan or opted-in self-funded plan

How to File:

  1. Download Form 216-A (External Review Request)
  2. Submit within 120 days of final internal denial
  3. Include denial letters and supporting medical records
  4. Send to: State Corporation Commission Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (urgent cases)
  • Decision is binding on the insurer

Contact Information:

Scripts & Templates

Patient Phone Script for Blue Cross Blue Shield Virginia

"Hi, I'm calling about prior authorization for Cosentyx, which is secukinumab. My member ID is [ID number]. My doctor submitted a PA request on [date], and I wanted to check the status. Can you tell me if it's been approved or if additional information is needed? If it was denied, can you please mail me the denial letter and tell me the specific reason for denial?"

Clinic Staff Script for Peer-to-Peer Request

"I'm calling to request a peer-to-peer review for [patient name], member ID [number]. We submitted a prior authorization for Cosentyx that was denied on [date]. Dr. [name] would like to speak with your medical director about the clinical rationale. The patient has severe plaque psoriasis with PASI score of [number] and has failed [list previous biologics]. When can we schedule this review?"

Email Template for Documentation Requests

Subject: Documentation Request for Cosentyx Prior Authorization

"Dear [Provider/Staff],

I need help gathering documentation for my Cosentyx prior authorization. Could you please provide:

  • Complete treatment history for my psoriasis/psoriatic arthritis
  • Records of previous biologic trials (names, dates, outcomes)
  • Most recent PASI score or disease severity assessment
  • Tuberculosis screening results from the past year
  • Photos of affected areas (if available)

Please let me know if you need me to sign any release forms. My insurance requires this documentation for approval.

Thank you, [Your name]"

When to Escalate to Virginia Regulators

Contact the Virginia State Corporation Commission Bureau of Insurance if:

  • Your health plan violates appeal deadlines
  • You're denied access to external review
  • The plan requests inappropriate or excessive documentation
  • You suspect discrimination or bad faith denial practices

Virginia Consumer Support:

  • Phone: (877) 310-6560
  • Email: [email protected]
  • Online complaint form: Available at scc.virginia.gov

The Bureau can investigate complaints, provide guidance on your rights, and help resolve disputes with health plans.

Costs & Patient Assistance Programs

Manufacturer Support

Novartis offers the Cosentyx Co-pay Program for eligible commercially insured patients. Benefits may include:

  • $5 co-pay for up to 24 months
  • Maximum annual benefit varies
  • Income and insurance restrictions apply

Foundation Assistance

Several foundations provide grants for biologic medications:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Patient Advocate Foundation

Virginia-Specific Resources

Virginia residents may qualify for additional assistance through:

  • Virginia Medicaid (if income-eligible)
  • 340B pharmacy programs at federally qualified health centers
  • Hospital charity care programs

Frequently Asked Questions

How long does Blue Cross Blue Shield Virginia prior authorization take?

Standard prior authorizations are processed within 7 business days. Urgent requests requiring immediate medical attention are processed within 72 hours. You can check status through the member portal or by calling the number on your insurance card.

What if Cosentyx is not on my formulary?

You can request a formulary exception if Cosentyx is not covered. Your doctor must demonstrate medical necessity and show that covered alternatives are inappropriate for your condition. This requires documentation of failed trials or contraindications to preferred drugs.

Can I request an expedited appeal in Virginia?

Yes, if your doctor certifies that waiting for a standard appeal could seriously harm your health. Use Form 216-C along with Form 216-A for expedited external review. Expedited reviews are decided within 72 hours for urgent cases.

Does step therapy apply if I tried biologics in another state?

Yes, documentation of previous biologic trials from any provider should count toward step therapy requirements. Ensure your current doctor has complete records from previous providers, including specific drug names, dates, dosages, and outcomes.

What happens if my appeal is denied?

After exhausting internal appeals, you can file for external review with the Virginia State Corporation Commission. If external review is also denied, you may have legal options or could explore alternative treatments with your doctor.

How much does Cosentyx cost without insurance?

Cosentyx typically costs $6,000-8,000 per month without insurance. However, Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions that align with each payer's specific requirements. Their platform helps patients, clinicians, and specialty pharmacies navigate the complex prior authorization process more effectively.

Can I get Cosentyx through a specialty pharmacy?

Yes, Cosentyx is typically dispensed through specialty pharmacies. Once approved, your insurance will direct you to their preferred specialty pharmacy network. Some patients may have options to choose their specialty pharmacy provider.

What if I have both Medicare and Blue Cross Blue Shield?

If you have dual coverage, coordination of benefits rules apply. Typically, Medicare would be primary, but this varies based on your specific situation. Contact both insurers to understand how prior authorization requirements work with dual coverage.

How Counterforce Health Can Help

Navigating prior authorization denials can be overwhelming, especially when you need important medications like Cosentyx. Counterforce Health transforms this complex process by analyzing denial letters, plan policies, and clinical notes to create targeted appeals that speak directly to your insurer's requirements.

Their platform identifies the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or medical necessity questions—and drafts point-by-point rebuttals using the right evidence. For Cosentyx appeals, this means pulling FDA labeling, peer-reviewed psoriasis studies, and dermatology guidelines while ensuring all clinical facts like diagnosis codes, prior treatment failures, and dosing rationale are properly documented.

The system is built around payer-specific workflows and produces letters that meet procedural requirements while tracking deadlines and required attachments. This comprehensive approach helps reduce the back-and-forth that often delays patient access to needed treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage varies by plan, and requirements may change. Verify current policies with your specific Blue Cross Blue Shield plan and consult Virginia insurance regulators for the most up-to-date appeal procedures.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.