By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Approved by Aetna CVS Health in North Carolina: Complete Prior Authorization Guide

Answer Box: Getting Cosentyx Approved by Aetna CVS Health in North Carolina

Eligibility: Patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, or hidradenitis suppurativa who meet step therapy requirements.

Fastest Path: Complete Aetna's Cosentyx precertification form, document prior therapy failures, submit TB screening results, and submit via provider portal or fax to 1-888-267-3277.

First Step Today: Contact your dermatologist or rheumatologist to request prior therapy documentation and schedule TB screening if not completed within the past 12 months.

North Carolina Advantage: If denied, you can appeal through Smart NC external review within 120 days for an independent decision.

Table of Contents

  1. What This Guide Covers
  2. Before You Start
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You Need to Provide Additional Information
  7. If Your Request Is Denied
  8. North Carolina Appeals Process
  9. Renewal and Re-Authorization
  10. Common Denial Reasons & Solutions
  11. Quick Reference Checklist
  12. Frequently Asked Questions

What This Guide Covers

This comprehensive guide helps North Carolina patients and their healthcare providers navigate Aetna CVS Health's prior authorization process for Cosentyx (secukinumab). Whether you're dealing with plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, or hidradenitis suppurativa, we'll walk you through every step from initial submission to potential appeals.

Cosentyx is an IL-17A inhibitor manufactured by Novartis that requires prior authorization from most insurance plans, including Aetna CVS Health. The good news? With proper documentation and understanding of Aetna's specific requirements, most medically appropriate requests are approved.

Who This Helps: Patients with Aetna CVS Health coverage in North Carolina, their caregivers, healthcare providers, and specialty pharmacies managing the prior authorization process.

Before You Start

Verify Your Plan Type and Coverage

First, confirm your specific Aetna plan details by checking your insurance card or logging into your member portal. Key information to verify:

  • Plan type (commercial, Medicare Advantage, Medicaid managed care)
  • Pharmacy benefit manager (typically CVS Caremark for Aetna plans)
  • Whether Cosentyx requires prior authorization for your specific plan
  • Formulary tier placement (usually Tier 4-6 for specialty biologics)

Confirm Network Status

Ensure your prescribing physician (dermatologist or rheumatologist) is in-network with your Aetna plan. Out-of-network providers may face additional hurdles in the prior authorization process.

Medical vs. Pharmacy Benefit

Cosentyx is typically covered under the pharmacy benefit and dispensed through specialty pharmacies like CVS Specialty. Confirm this with your plan to ensure you're following the correct prior authorization pathway.

Gather Required Documentation

Essential Clinical Information

Diagnosis Documentation with appropriate ICD-10 codes:

  • Plaque Psoriasis: L40.0 (requires BSA ≥3%, PASI score ≥10, or functional impairment)
  • Psoriatic Arthritis: L40.50 (unspecified), L40.51 (distal interphalangeal), L40.52 (multiple sites)
  • Ankylosing Spondylitis: M45
  • Hidradenitis Suppurativa: L73.2 (with Hurley stage documentation)

Prior Therapy Documentation

Aetna requires documented failure or intolerance of specific therapies before approving Cosentyx:

For Plaque Psoriasis:

  • Failed topical treatments (corticosteroids, vitamin D analogs, tazarotene)
  • Inadequate response to phototherapy (if applicable)
  • Documentation of specific therapy duration and dosing

For Psoriatic Arthritis:

  • Minimum 12-16 week trial of methotrexate at appropriate doses
  • Failed NSAID trial (minimum 4 weeks) for axial disease or enthesitis
  • Documentation of intolerance or contraindications if trials were shortened

For Ankylosing Spondylitis:

  • Failed adequate trial of NSAIDs with documented dose and duration
  • Baseline inflammatory markers (CRP/ESR)

Required Safety Screening

Tuberculosis Screening (mandatory):

  • TB skin test (PPD) or interferon-gamma release assay (IGRA) within 12 months
  • Chest X-ray if TB screening is positive
  • If latent TB is present, treatment must begin before Cosentyx initiation

Official Forms and Submission Methods

Download and complete Aetna's Cosentyx precertification form. This form requires:

  • Patient demographics and insurance information
  • Prescriber credentials and NPI number
  • Clinical rationale for use
  • Prior therapy history with specific dates and outcomes
  • TB screening results

Submit Your Prior Authorization Request

Submission Options

Online Portal (Preferred):

  • Use the Availity provider portal for fastest processing
  • Upload all required documents as PDF attachments
  • Receive electronic confirmation of submission

Fax Submission:

  • Fax completed form and documentation to 1-888-267-3277
  • Include a cover sheet with patient information and total page count
  • Request fax confirmation receipt

Phone Submission:

  • Call 1-866-752-7021 for urgent cases
  • Have all documentation ready for verbal review
  • Request reference number for tracking

Clean Request Packet Checklist

✅ Completed Cosentyx precertification form ✅ Current prescription with diagnosis ✅ Clinical notes supporting medical necessity ✅ Prior therapy documentation with dates and outcomes ✅ TB screening results (within 12 months) ✅ Relevant lab results or imaging ✅ Patient insurance card copy

Tip: Submit requests at least two weeks before the patient needs to start therapy to allow for processing time and potential requests for additional information.

Follow-Up and Timeline Management

Standard Processing Times

  • Standard requests: 30-45 days for determination
  • Expedited requests: 72 hours for urgent cases
  • Medicare plans: Decisions typically within 72 hours

When and How to Follow Up

Day 3-5: Call to confirm receipt if no electronic confirmation received Day 10-14: Check status if no decision rendered Day 20: Escalate if approaching deadline without response

Status Check Script: "Hi, I'm calling to check the status of a Cosentyx prior authorization for [patient name], DOB [date], member ID [number]. The reference number is [if available]. Can you tell me the current status and expected timeline for a decision?"

Document all interactions with reference numbers, representative names, and next steps.

If You Need to Provide Additional Information

Aetna may request additional clinical information to support medical necessity. Common requests include:

Medical Necessity Clarifications

  • Disease severity measures: PASI scores, joint counts, functional assessments
  • Treatment goals: Specific targets for improvement
  • Contraindications: Why standard therapies cannot be used
  • Dosing rationale: Why standard dosing is appropriate

Literature Support

When requested, provide peer-reviewed evidence supporting Cosentyx use:

  • FDA prescribing information
  • Clinical practice guidelines from dermatology or rheumatology societies
  • Peer-reviewed studies demonstrating efficacy for your patient's condition
Note: Respond to requests for additional information within the specified timeframe (typically 14 days) to avoid automatic denial.

If Your Request Is Denied

Understanding Denial Reasons

Common denial codes and their meanings:

  • Step therapy not met: Prior required therapies not documented
  • Not medically necessary: Insufficient clinical justification
  • Non-formulary: Drug not on preferred list (requires formulary exception)
  • Quantity limits exceeded: Requesting more than standard dosing

First-Level Appeal Process

You have 180 days from the denial date to file your first internal appeal with Aetna. Submit:

  • Completed appeal form
  • Original denial letter
  • Additional clinical documentation addressing denial reason
  • Updated medical necessity letter from prescriber

North Carolina Appeals Process

Smart NC External Review

If Aetna upholds their denial after internal appeals, North Carolina residents can request independent external review through Smart NC.

Timeline:

  • File within 120 days of final Aetna denial
  • Standard review: Decision within 45 days
  • Expedited review: Decision within 72 hours for urgent cases

How to Request:

  • Complete Smart NC external review form
  • Submit all medical records and denial letters
  • Include documentation of specific denial reason
  • No cost to patient

Contact Smart NC:

  • Phone: 1-855-408-1212
  • Free advocacy and guidance available
  • Can help gather supporting documentation

When healthcare coverage decisions feel overwhelming, specialized services like Counterforce Health can help patients and providers navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals that align with each payer's specific requirements.

External Review Requirements

Smart NC external review is available for:

  • State-regulated plans (not self-funded employer plans)
  • Denials based on medical necessity
  • Experimental treatment determinations
  • After exhausting internal appeals (or qualifying for expedited review)

The Independent Review Organization's decision is binding on Aetna – if they approve coverage, Aetna must provide it within 3 business days.

Renewal and Re-Authorization

When to Resubmit

Most Cosentyx approvals are granted for 12 months. Calendar reminders should be set for:

  • 90 days before expiration: Begin renewal process
  • 60 days before expiration: Submit renewal request
  • 30 days before expiration: Follow up if no decision

Renewal Documentation

Include updated information showing:

  • Treatment response and clinical improvement
  • Continued medical necessity
  • Any new contraindications to alternative therapies
  • Current disease activity measures

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document prior therapy failures Detailed therapy history with dates, doses, outcomes
Insufficient disease severity Provide objective measures PASI scores, joint counts, functional assessments
TB screening incomplete Submit screening results TB skin test or IGRA within 12 months
Non-formulary status Request formulary exception Comparative effectiveness data, clinical rationale
Quantity limits Justify dosing FDA labeling, clinical guidelines supporting dose

Quick Reference Checklist

Before Submitting:

  • Verify Aetna plan requires PA for Cosentyx
  • Confirm prescriber is in-network
  • Gather all required clinical documentation
  • Complete TB screening if needed
  • Download current Cosentyx precertification form

Submission:

  • Complete all form fields accurately
  • Attach all supporting documents
  • Submit via preferred method (portal > fax > phone)
  • Request confirmation of receipt
  • Document reference number

Follow-Up:

  • Check status at appropriate intervals
  • Respond promptly to requests for additional information
  • Escalate if approaching deadlines
  • Prepare for potential appeals process

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in North Carolina? Standard requests typically take 30-45 days, while expedited requests for urgent cases are decided within 72 hours.

What if Cosentyx is non-formulary on my plan? You can request a formulary exception by providing clinical documentation showing why formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal if my condition is urgent? Yes, both Aetna and Smart NC offer expedited review processes (72 hours) for situations where delays could seriously impact your health.

Does step therapy apply if I've failed treatments outside North Carolina? Yes, documented treatment failures from other states count toward step therapy requirements as long as proper documentation is provided.

What happens if I start Cosentyx before approval? Starting therapy before approval may result in denial and patient responsibility for costs. Always wait for approval unless it's an emergency situation.

Can Smart NC help me prepare my external review request? Yes, Smart NC staff provide free guidance and can help you gather documentation, though they cannot serve as your official representative.

How much does Cosentyx cost if not covered? Cosentyx is a specialty biologic with high costs. Check with Novartis for patient assistance programs and copay cards that may help reduce out-of-pocket expenses.

What should I do if my doctor's office won't help with the prior authorization? Contact Counterforce Health or similar advocacy services that specialize in helping patients navigate complex insurance approval processes.

Sources & Further Reading

Disclaimer: This guide is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current coverage information. Prior authorization requirements and appeal processes may change. For personalized assistance with complex coverage issues, consider consulting with healthcare advocacy services.

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