By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Blue Cross Blue Shield in California: Prior Authorization Guide and Appeals Process

Quick Answer: Getting Cosentyx Covered by Blue Cross Blue Shield in California

Cosentyx (secukinumab) is a preferred IL-17 inhibitor on Blue Shield of California formularies but requires prior authorization with step therapy through TNF inhibitors first. To get coverage: (1) Submit PA documentation including diagnosis codes, prior therapy failures, and TB screening through your provider portal, (2) Request step therapy exception if TNF inhibitors failed or are contraindicated, (3) If denied, file internal appeal within 180 days, then California's Independent Medical Review (IMR) for binding external review. Success rates improve with thorough medical necessity documentation and specialist support.

First step today: Contact your prescribing rheumatologist or dermatologist to initiate the prior authorization process and gather documentation of any prior biologic failures.

Table of Contents

When Alternatives Make Sense vs. Fighting for Cosentyx

Before pursuing a lengthy appeal process, consider whether Blue Cross Blue Shield's preferred alternatives might work for your condition. Cosentyx is listed as preferred on Blue Shield of California's Performance and Standard specialty drug lists, but step therapy requirements often mandate trying TNF inhibitors first.

When Alternatives Are Worth Trying

For treatment-naïve patients, Blue Cross Blue Shield's preferred biologics often provide excellent outcomes:

  • TNF inhibitors like adalimumab biosimilars (Hadlima) and Enbrel show comparable efficacy in psoriatic arthritis and ankylosing spondylitis
  • IL-23 inhibitors like Skyrizi (risankizumab) excel in plaque psoriasis with less frequent dosing
  • Oral JAK inhibitors like Rinvoq offer convenience for some patients

When to Fight for Cosentyx Specifically

Push for Cosentyx when you have:

  • TNF inhibitor failures or intolerances (documented in medical records)
  • Active inflammatory bowel disease (TNF inhibitors preferred; Cosentyx may worsen IBD)
  • Contraindications to preferred agents (e.g., heart failure with TNF inhibitors)
  • Stability on Cosentyx from prior insurance coverage

Blue Cross Blue Shield California Formulary Alternatives

Based on Blue Shield of California's 2026 formulary, here are the preferred alternatives typically required before Cosentyx:

TNF-α Inhibitors (First-Line Step Therapy)

Drug Administration Notes
Adalimumab biosimilars (adalimumab-aacf, -aaty, -adaz) Subcutaneous every other week Often preferred; equivalent to Humira
Hadlima (adalimumab-bwwd) Subcutaneous every other week Preferred on Performance formulary
Enbrel (etanercept) Subcutaneous weekly Preferred option for multiple indications

IL-17/IL-23 Inhibitors (After TNF Failure)

Drug Mechanism Indications
Skyrizi (risankizumab) IL-23 inhibitor Psoriasis, psoriatic arthritis
Cosentyx (secukinumab) IL-17A inhibitor Preferred after step therapy
Bimzelx (mirikizumab) IL-23 inhibitor Step after Cosentyx/Enbrel

Other Options

  • Stelara (ustekinumab): IL-12/23 inhibitor for psoriatic arthritis and ankylosing spondylitis
  • Rinvoq (upadacitinib), Xeljanz (tofacitinib): Oral JAK inhibitors with enhanced cardiovascular monitoring requirements

Pros and Cons: Access Considerations

Advantages of Preferred Alternatives

Faster access: TNF inhibitors like adalimumab biosimilars typically get approved within 72 hours with proper documentation.

Lower out-of-pocket costs: Preferred tier placement often means lower copays or coinsurance.

Established track record: Long-term safety and efficacy data available for TNF inhibitors.

When Cosentyx May Be Worth the Fight

Superior skin clearance: Clinical trials show higher PASI90/100 rates with Cosentyx compared to some TNF inhibitors.

Different mechanism: IL-17A inhibition works through a different pathway than TNF inhibitors, beneficial for TNF failures.

High persistence rates: Real-world data shows 83% persistence at 24 months for first-line Cosentyx use.

Monitoring considerations: All biologics require TB screening and infection monitoring, but Cosentyx has a lower risk of reactivating latent tuberculosis compared to TNF inhibitors.

Exception Strategy: When to Request Cosentyx

Medical Necessity Documentation

Your specialist should include these elements in the prior authorization request:

Diagnosis documentation:

  • ICD-10 codes: L40.0-L40.9 (psoriasis), M07.6 (psoriatic arthritis), M45 (ankylosing spondylitis)
  • Disease severity measures (PASI score, BSA involvement, joint counts)
  • Impact on quality of life and function

Prior therapy failures:

  • Specific medications tried, dosages, and duration
  • Reasons for discontinuation (lack of efficacy, intolerance, contraindications)
  • Documentation from medical records or prior insurance approvals

Clinical rationale:

  • Why Cosentyx is medically necessary for this specific patient
  • Relevant clinical guidelines supporting IL-17A inhibitor use
  • Expected outcomes and monitoring plan

Supporting Evidence

Include peer-reviewed evidence when possible:

  • MEASURE trials showing 61% ASAS20 response rates for ankylosing spondylitis
  • FUTURE trials demonstrating efficacy in TNF-experienced psoriatic arthritis patients
  • FDA labeling for approved indications and dosing
From our advocates: "We've seen the strongest Cosentyx approvals when providers document specific TNF inhibitor failures with dates, dosages, and clear reasons for discontinuation. Generic statements like 'failed prior biologics' rarely succeed, but detailed records showing a 6-month Humira trial with inadequate joint response often do."

Switching Logistics and Coordination

Provider Coordination

Specialist involvement: Work with your rheumatologist or dermatologist who can:

  • Submit prior authorization requests through provider portals
  • Coordinate timing between stopping current therapy and starting Cosentyx
  • Provide medical necessity letters with clinical justification

Timing considerations:

  • From Enbrel: Start Cosentyx 1 week after last dose
  • From Humira: Start Cosentyx 2 weeks after last dose
  • No washout needed for lack of efficacy switches

Pharmacy Coordination

Blue Shield of California requires specialty pharmacy dispensing for Cosentyx. Common networks include:

  • CarelonRx (formerly InnovaCare)
  • BioPlus Specialty Pharmacy
  • Plan-specific specialty networks

Processing timeline: Allow 7-10 days for specialty pharmacy coordination and first shipment.

Laboratory Requirements

Before switching to Cosentyx, ensure current:

  • TB screening (chest X-ray and QuantiFERON-Gold)
  • Hepatitis B screening
  • Complete blood count
  • Liver function tests

Re-trying for Cosentyx Later

Documenting Alternative Therapy Trials

If you start with a preferred alternative, document the following to strengthen a future Cosentyx request:

Treatment response tracking:

  • PASI scores for psoriasis (target: ≥75% improvement)
  • Joint counts and pain scores for psoriatic arthritis
  • BASDAI scores for ankylosing spondylitis
  • Functional assessments (HAQ, BASFI)

Adverse events or limitations:

  • Injection site reactions
  • Infection frequency
  • Laboratory abnormalities
  • Quality of life impacts

Timing for reassessment: Most biologics receive adequate trials of 3-6 months before considering switches.

Prior Authorization Requirements

Required Documentation

Submit through your provider's Blue Cross Blue Shield portal with:

Patient information:

  • Insurance card and member ID
  • Complete demographic information
  • Prescribing provider details

Clinical documentation:

  • Diagnosis codes with supporting documentation
  • Prior therapy records with dates and outcomes
  • Current disease severity assessments
  • TB screening results (mandatory)

Processing timeline:

  • Standard PA decision: 72 hours
  • Urgent PA decision: 24 hours for cases meeting medical urgency criteria

Blue Shield of California Specific Criteria

For moderate to severe plaque psoriasis, Blue Shield requires:

  • Patient at least 6 years old
  • Prescription by or consultation with rheumatologist or dermatologist
  • Inadequate response to one conventional agent (methotrexate, cyclosporine, or acitretin)
  • PASI score ≥10, body surface area ≥3%, or sensitive area involvement

Appeals Process in California

Internal Appeal (Level 1)

Timeline: File within 180 days of denial Process: Submit through member portal or mail with:

  • Copy of denial letter
  • Additional medical documentation
  • Updated physician letter addressing denial reasons
  • Supporting clinical literature

Decision timeline: 30 days (expedited: 72 hours for urgent cases)

Independent Medical Review (IMR)

California's external review process provides binding decisions on medical necessity denials.

Eligibility: Available for fully insured plans regulated by DMHC (most HMOs and managed care plans)

Filing process:

  • Submit through DMHC IMR portal within 6 months of denial
  • No fee required
  • Include all relevant medical records and supporting evidence

Timeline: 30 days for standard review, 3 days for expedited urgent cases

Success rates: Overall IMR drug overturn rate is 9.4%, with biologics often having higher success rates when medical necessity is well-documented.

When to Request Expedited Review

Request urgent review if delay would cause:

  • Serious health deterioration
  • Risk of hospitalization
  • Rapid disease progression
  • Functional impairment

Your provider must certify medical urgency for expedited appeals.

Cost and Savings Options

Manufacturer Support

Novartis Copay Program: 84% of eligible patients pay $0 with commercial insurance (income restrictions apply)

Patient assistance programs: Available for uninsured or underinsured patients through Novartis Patient Assistance Foundation

State and Foundation Resources

  • Health Consumer Alliance: Free assistance with appeals and IMR applications
  • Legal aid organizations: Help with complex insurance disputes
  • California's prescription drug discount programs for eligible residents

FAQ

Q: How long does Blue Cross Blue Shield PA take in California? A: Standard prior authorization decisions are made within 72 hours. Urgent requests receive decisions within 24 hours if medical urgency criteria are met.

Q: What if Cosentyx is non-formulary on my specific plan? A: Request a formulary exception with medical necessity documentation. If denied, California's IMR process can provide binding external review of medical necessity determinations.

Q: Can I request an expedited appeal? A: Yes, if your provider certifies that delay would cause serious health deterioration, risk of hospitalization, or rapid disease progression. Expedited IMRs are decided within 72 hours.

Q: Does step therapy apply if I've failed biologics outside California? A: Yes, document out-of-state biologic trials in your PA submission. California law accepts prior therapy failures from any state for step therapy exception requests.

Q: What's the difference between internal appeals and IMR? A: Internal appeals are reviewed by your insurance company. IMR is California's independent external review process with binding decisions made by physician experts not employed by your insurer.

Q: How much does Cosentyx cost without insurance? A: List price is approximately $8,492 per month as of January 2026, but manufacturer copay programs and patient assistance are available.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right citations and clinical evidence to support your case. Learn more about our coverage advocacy services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with insurance appeals and coverage issues in California, contact the DMHC Help Center at 888-466-2219 or visit healthhelp.ca.gov.

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