By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Aetna CVS Health in Pennsylvania: Complete Guide with Forms and Appeal Scripts

Answer Box: Getting Cosentyx Covered by Aetna CVS Health in Pennsylvania

Aetna CVS Health requires prior authorization for Cosentyx (secukinumab) in Pennsylvania, with step therapy requirements for most patients. Fastest path to approval: 1) Ensure TB screening is complete, 2) Document prior treatment failures (typically methotrexate or other biologics), and 3) Submit Aetna's precertification form via fax (1-888-267-3277) or phone (1-866-752-7021). If denied, Pennsylvania's new external review program overturns about 50% of appeals. Start today by calling your dermatologist or rheumatologist to begin prior authorization paperwork.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Aetna plans 2024 Precert List (PDF)
Specialist Prescriber Dermatologist or rheumatologist required Aetna Clinical Policy
Step Therapy Prior biologic or targeted therapy usually required Cosentyx Precert Form
TB Screening TST or IGRA required before treatment Aetna Clinical Policy
Quantity Limits One 300mg dose per 28 days standard Specialty Quantity Limits

Step-by-Step: Fastest Path to Approval

1. Complete TB Screening (Patient/Clinic)

  • Get tuberculosis skin test (TST) or blood test (QuantiFERON)
  • If positive, complete latent TB treatment first
  • Timeline: 1-2 weeks for results
  • Source: Aetna Clinical Policy

2. Document Prior Treatment Failures (Clinic)

  • Gather records of methotrexate, phototherapy, or other biologic failures
  • Include specific doses, duration, and reasons for discontinuation
  • Timeline: Same day if records are organized
  • Source: Cosentyx Precert Form

3. Complete Prior Authorization Form (Clinic)

  • Use Aetna's official Cosentyx precertification form
  • Include all required fields: diagnosis, ICD-10, prior therapies, clinical rationale
  • Timeline: 30 minutes to complete thoroughly

4. Submit to Aetna (Clinic)

5. Await Decision (Patient/Clinic)

  • Standard review: 30-45 days
  • Expedited review: 72 hours (if urgent)
  • Timeline: Varies by request type

6. If Approved, Fill at CVS Specialty (Patient)

  • Aetna uses CVS Specialty for most biologics
  • Coordinate delivery and injection training
  • Timeline: 3-5 business days for first fill

7. If Denied, Begin Appeal Process (See Appeals Section)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Step therapy not met Document specific prior biologic failures with doses, duration, and adverse effects. Submit medical records showing inadequate response.
Not medically necessary Include disease severity measures (BSA, PASI score), functional impact, and guideline citations supporting Cosentyx use.
Missing TB screening Submit TST or IGRA results. If positive, provide documentation of completed latent TB treatment.
Non-formulary status Request formulary exception with comparative effectiveness data and clinical rationale for Cosentyx over preferred agents.
Quantity limits exceeded Provide clinical justification for higher doses, including weight-based calculations or disease severity requiring loading dose.

Appeals Playbook for Pennsylvania

Internal Appeal (First Level)

  • Deadline: 180 days from denial
  • How to file: Aetna member portal or written request
  • Timeline: 30 days for standard, 72 hours for urgent
  • Required: Denial letter, additional clinical documentation

Peer-to-Peer Review (Optional)

  • Deadline: 14 days from denial
  • Phone: 1-833-491-1090 (verify for your specific plan)
  • Timeline: Usually scheduled within 5 business days
  • Tip: Request reviewer credentials match your specialist
From our advocates: We've seen dermatologists successfully overturn Cosentyx denials during peer-to-peer calls by emphasizing patient-specific contraindications to preferred agents and referencing AAD guidelines. The key is having all clinical data organized before the call and asking the reviewing physician about their specialty training.

Pennsylvania External Review (Final Level)

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results: about 50% of appealed denials are overturned.

Eligibility:

  • Must complete Aetna's internal appeals first
  • Receive Final Adverse Benefit Determination letter
  • Have employer, marketplace, or individual coverage (not Medicaid/Medicare)

How to File:

Required Documents:

  • Final denial letter from Aetna
  • Insurance card copy
  • Medical records supporting need for Cosentyx
  • Physician Certification Form (for expedited review)

Clinician Corner: Medical Necessity Letter

Essential Elements for Cosentyx Medical Necessity:

  1. Patient Profile
    • Age, weight, diagnosis with ICD-10 codes
    • Disease duration and severity measures
    • Impact on quality of life and function
  2. Prior Treatment History
    • Specific medications tried (generic and brand names)
    • Doses, duration, and outcomes
    • Reasons for discontinuation (inefficacy, intolerance, contraindications)
  3. Clinical Rationale for Cosentyx
    • FDA-approved indication match
    • Expected clinical benefits
    • Why preferred agents are inappropriate
  4. Supporting Evidence
    • Reference FDA prescribing information
    • Cite relevant guidelines (AAD for psoriasis, ACR for psoriatic arthritis)
    • Include disease severity scores if available
  5. Safety Considerations
    • TB screening results
    • Contraindications to alternatives ruled out
    • Monitoring plan

Scripts & Templates

Patient Phone Script for Aetna

"Hi, I'm calling about prior authorization for Cosentyx. My member ID is [ID number]. My dermatologist submitted the request on [date]. Can you tell me the status and if any additional information is needed? If it's been denied, I'd like to understand the specific reasons and next steps for appeal."

Clinic Staff Peer-to-Peer Request

"I'm calling to request a peer-to-peer review for [patient name], member ID [number], regarding the Cosentyx denial dated [date]. The treating physician is a board-certified [dermatologist/rheumatologist]. Can we schedule a call with a medical director who has equivalent specialty training? We have additional clinical information that wasn't considered in the initial review."

When to Escalate: Pennsylvania's External Review

If Aetna upholds their denial after internal appeals, Pennsylvania's external review program offers real hope. In 2024, the program reviewed 517 cases and overturned 259 denials—a 50% success rate.

Key Success Factors:

  • Submit within the 4-month deadline
  • Include comprehensive medical records
  • Have your physician complete supporting documentation
  • Emphasize FDA approval and guideline support for your specific condition

Contact Information:

  • Pennsylvania Insurance Department: External Review webpage
  • Consumer Services: Available through the PID website for guidance

FAQ

Q: How long does Aetna CVS Health prior authorization take for Cosentyx in Pennsylvania? A: Standard reviews typically take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours. [Source: Aetna policy documents]

Q: What if Cosentyx isn't on my Aetna formulary? A: You can request a formulary exception by providing clinical documentation that preferred alternatives are inappropriate. Your doctor must demonstrate medical necessity for Cosentyx specifically.

Q: Does step therapy apply if I tried biologics with a different insurance company? A: Yes, prior treatment failures with any insurance typically count toward step therapy requirements. Provide complete medical records documenting previous therapies and outcomes.

Q: Can I get an expedited appeal for Cosentyx? A: Yes, if your physician certifies that delays could seriously jeopardize your health. Both Aetna's internal expedited appeals (72 hours) and Pennsylvania's expedited external review (72 hours) are available.

Q: What's the difference between CVS Specialty and CVS Caremark? A: CVS Specialty handles most biologics like Cosentyx, providing specialized packaging, delivery, and injection support. CVS Caremark manages the pharmacy benefit and prior authorization process.

Q: Are there cost assistance programs for Cosentyx? A: Yes, Novartis offers the Cosentyx Co-pay Program for eligible patients. Additional assistance may be available through patient advocacy foundations.

About Coverage Appeals: Getting specialty medications approved often requires persistence and detailed documentation. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

Whether you're navigating Aetna's prior authorization process or preparing for Pennsylvania's external review, having the right documentation and understanding payer-specific workflows can make the difference between approval and denial. The key is matching your clinical evidence to the insurer's stated criteria while leveraging Pennsylvania's consumer-friendly appeals environment.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. For official appeals guidance, contact the Pennsylvania Insurance Department or Aetna directly.

Sources & Further Reading

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