By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Approved by Humana in Florida: Complete Prior Authorization Guide

Quick Answer: Getting Cosentyx Approved by Humana in Florida

Cosentyx (secukinumab) requires prior authorization from Humana in Florida, with step therapy typically required first. The fastest path to approval: 1) Verify your plan covers specialty drugs through CenterWell Specialty Pharmacy, 2) Have your dermatologist submit a PA request with documented PASI score ≥10 and failed systemic therapies, and 3) Request a peer-to-peer review if initially denied. Appeals must be filed within 65 days, with decisions due in 7 days for Part D plans.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Coverage Requirements at a Glance
  4. What You'll Need to Gather
  5. Step-by-Step: Submitting Your PA Request
  6. Follow-Up and Tracking
  7. Common Denial Reasons and Solutions
  8. Appeals Process for Humana in Florida
  9. Renewal and Reauthorization
  10. Cost-Saving Resources
  11. FAQ

What This Guide Covers

This guide helps Florida patients with Humana Medicare Advantage, Medicare Part D, or Medicaid plans navigate the 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 exactly what Humana requires and how to strengthen your approval chances.

Cosentyx is an IL-17A inhibitor that typically costs thousands per month without insurance coverage. With proper documentation and persistence, most medically appropriate requests eventually get approved—but the process requires attention to detail and timely follow-through.

Before You Start: Plan Verification

Step 1: Confirm Your Plan Type

  • Log into your Humana member portal or call the number on your insurance card
  • Verify whether you have Medicare Advantage (Part C), Medicare Part D, or Medicaid
  • Note your plan's effective date and formulary year

Step 2: Check Specialty Pharmacy Requirements Humana requires specialty medications like Cosentyx to be dispensed through CenterWell Specialty Pharmacy or another in-network specialty pharmacy. Standard retail pharmacies cannot fill this prescription.

Step 3: Verify Formulary Status Use Humana's drug list tool to confirm Cosentyx is covered under your specific plan. It's typically classified as a nonpreferred specialty drug (Tier 5), which means higher cost-sharing until you reach your out-of-pocket maximum.

Coverage Requirements at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all Cosentyx formulations Humana PA Lists
Step Therapy Must try preferred alternatives first Plan formulary or PA policy
Specialty Pharmacy CenterWell or in-network specialty only Pharmacy Finder
Provider Requirement Dermatologist consultation/oversight PA form requirements
Medical Necessity PASI ≥10 or BSA ≥10% documentation Clinical notes and assessment
Appeal Deadline 65 days from denial notice Denial letter instructions

What You'll Need to Gather

Clinical Documentation:

  • Confirmed diagnosis with ICD-10 codes (L40.0 for plaque psoriasis, M07.3- for psoriatic arthritis)
  • PASI score ≥10 or Body Surface Area (BSA) ≥10%, or documentation of significant quality of life impact
  • Complete list of previous systemic therapies tried (methotrexate, cyclosporine, acitretin, phototherapy)
  • Documentation of inadequate response, intolerance, or contraindications to prior treatments
  • Current clinical notes from dermatologist or rheumatologist

Insurance Information:

  • Member ID and group number
  • Prescribing provider NPI and contact information
  • Preferred specialty pharmacy selection

Forms and Contacts:

Step-by-Step: Submitting Your PA Request

1. Provider Initiates Request (Timeline: Day 0) Your dermatologist or rheumatologist submits the PA request through Humana's provider portal or by fax. The request must include all clinical documentation supporting medical necessity.

2. Humana Reviews Request (Timeline: 7 days standard, 72 hours expedited) Humana's clinical team reviews the submission against their medical necessity criteria. For urgent cases, request expedited review.

3. Decision Notification You and your provider receive written notification of approval or denial. Approvals typically include quantity limits and duration of coverage.

Tip: Request a peer-to-peer review with Humana's medical director if your initial request seems likely to be denied. This conversation often resolves coverage issues before a formal denial.

Follow-Up and Tracking

Week 1: Call Humana at 1-866-488-5995 (Medicare-related PA questions) to confirm receipt and get a reference number.

Sample Script: "I'm calling to check the status of a prior authorization request for Cosentyx submitted by Dr. [Name] on [date]. My member ID is [number]. Can you provide the reference number and expected decision timeline?"

Document everything: Keep records of all phone calls, reference numbers, and correspondence dates.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Step therapy not completed Document medical necessity for bypassing preferred agents or provide evidence of failed trials with TNF inhibitors, methotrexate, or other systemic therapies
Insufficient severity documentation Submit updated PASI score ≥10, BSA measurements, or quality of life assessments showing significant impact
Provider not specialized Ensure dermatologist or rheumatologist is prescribing or consulting
Missing clinical notes Provide comprehensive treatment history and current assessment from specialist
Combination therapy concerns Confirm Cosentyx won't be used with other immunomodulators

Appeals Process for Humana in Florida

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Decision Timeline: 7 days for Part D, 72 hours if expedited
  • Submission: Mail to address on denial letter or submit through member portal

Peer-to-Peer Review Request this immediately after denial and before or during the appeal process. Your prescribing physician can speak directly with Humana's medical director to discuss the clinical rationale.

External Review (If Internal Appeal Fails) If Humana doesn't respond within required timelines or upholds the denial, your case automatically advances to an Independent Review Entity (IRE). This binding decision typically comes within 7 days of assignment.

Florida State Resources For additional help, contact the Florida Department of Financial Services Division of Consumer Services at 1-877-693-5236.

From our advocates: We've seen cases where a well-documented peer-to-peer review resolved step therapy requirements when the prescribing dermatologist clearly explained why first-line agents weren't appropriate due to the patient's specific contraindications and disease severity. The key was having quantified PASI scores and detailed documentation of prior therapy outcomes ready for the conversation.

Renewal and Reauthorization

Humana typically requires reauthorization every 6-12 months. Start the renewal process 30-45 days before your current authorization expires.

Renewal Documentation:

  • Evidence of positive clinical response (improved PASI, BSA, or quality of life measures)
  • Continued specialist oversight
  • Confirmation that combination therapy restrictions are still met
  • Updated clinical assessment

Cost-Saving Resources

Manufacturer Support:

  • Cosentyx Co-pay Program may reduce out-of-pocket costs for eligible patients
  • Patient assistance programs available for qualifying low-income patients

Medicare Part D Protection: Under Humana's 2025-2026 Part D plans, your annual out-of-pocket maximum is $2,100. After reaching this threshold, Humana pays 100% of covered medication costs for the rest of the year.

When navigating complex prior authorization requirements, platforms like Counterforce Health can help patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to plan policies.

FAQ

How long does Humana prior authorization take in Florida? Standard requests: 7 days. Expedited requests (for urgent medical needs): 72 hours. Medicare Part D follows these federal timelines.

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. This requires additional clinical documentation.

Can I get an expedited appeal if denied? Yes, if delay could seriously harm your health. Expedited appeals must be decided within 72 hours of receipt.

Does step therapy apply if I failed therapies in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your Florida provider has complete records.

What counts as medical necessity for Cosentyx? PASI score ≥10, BSA ≥10%, or significant quality of life impact from psoriasis involving hands, feet, face, or genitals, plus inadequate response to at least one systemic therapy.

How do I find Humana's current PA form? Check the Humana provider portal or call 1-866-488-5995 to verify the most current form and submission requirements.

Printable Checklist

Before Starting:

  • Verify specialty pharmacy network requirements
  • Confirm Cosentyx formulary status and tier
  • Gather PASI/BSA documentation
  • Document prior therapy failures

During PA Process:

  • Submit complete clinical documentation
  • Get reference number and timeline
  • Request peer-to-peer if needed
  • Track all communications

If Denied:

  • File appeal within 65 days
  • Request expedited review if urgent
  • Consider external review options
  • Contact Florida consumer services if needed

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana directly and consult your healthcare provider for medical decisions. For personalized assistance with complex coverage issues, consider working with healthcare advocacy services like Counterforce Health that specialize in insurance appeals and prior authorization support.

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