By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Blue Cross Blue Shield in New Jersey: 2025 PA Rules, Appeals, and Step Therapy Overrides

Answer Box: Your Fastest Path to Cosentyx Coverage

Getting Cosentyx (secukinumab) approved by Blue Cross Blue Shield in New Jersey requires prior authorization, but New Jersey's 2026 step therapy reform (A1825) strengthens your rights. Submit your PA request through Horizon BCBS's provider portal, documenting inadequate response or contraindications to preferred alternatives. If denied, you have 72 hours for step therapy override requests and can appeal to New Jersey's Independent Health Care Appeals Program (IHCAP) within 4 months. Start today: Gather your diagnosis codes, prior treatment records, and TB screening results—then work with your prescriber to submit the PA with medical necessity documentation.

Table of Contents

  1. Why New Jersey State Rules Matter
  2. Prior Authorization Requirements
  3. New Jersey Step Therapy Protections (2026)
  4. Turnaround Standards and Deadlines
  5. Appeals Process: Internal and External
  6. Continuity of Care Protections
  7. Common Denial Reasons and Solutions
  8. Practical Scripts and Templates
  9. When to Contact State Regulators
  10. FAQ

Why New Jersey State Rules Matter

New Jersey's healthcare landscape provides robust consumer protections that work alongside Blue Cross Blue Shield policies. As the state's largest insurer with approximately 39% market share, Horizon Blue Cross Blue Shield of New Jersey must comply with state-specific requirements that can override certain plan restrictions.

The key difference in New Jersey: state-regulated plans (individual, small group, fully-insured large group, and NJ FamilyCare) receive stronger protections than self-funded ERISA plans. Most New Jersey residents with employer coverage through Horizon BCBS fall under state jurisdiction, giving them access to step therapy override rights and external appeal protections.

Note: Self-funded employer plans may voluntarily adopt these protections but aren't legally required to follow state step therapy laws.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cosentyx prescriptions Horizon Provider Portal
Formulary Status Tier 2-3 with quantity limits 2025 NJ Marketplace Formulary
Step Therapy Required trial of preferred agents BCBS Medical Policy (verify current version)
Specialist Requirement Dermatologist or rheumatologist Standard BCBS criteria
Age Restrictions FDA-approved ages (≥6 for psoriasis, ≥2 for PsA) FDA Cosentyx Label

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic): Call Horizon member services at 1-800-682-9090 or check the provider portal for current formulary status and PA requirements.
  2. Gather Documentation (Clinic): Collect diagnosis codes (L40.50-L40.59 for psoriasis, M07.6 for PsA), prior treatment records showing inadequate response to preferred agents, and TB screening results.
  3. Submit PA Request (Prescriber): Use Horizon's online provider portal or fax the completed prior authorization form with supporting clinical documentation.
  4. Include Medical Necessity Letter (Prescriber): Document specific reasons why Cosentyx is medically necessary, addressing any step therapy requirements with evidence of prior failures.
  5. Track Timeline (Clinic): Standard PA decisions: 72 hours for non-urgent, 24 hours for urgent requests after all information is received.
  6. Request Peer-to-Peer if Denied (Prescriber): Within 7 business days of denial, request a medical director consultation to discuss the clinical rationale.
  7. File Appeals if Needed (Patient/Prescriber): Internal appeals within 180 days, external IHCAP appeals within 4 months of final denial.

New Jersey Step Therapy Protections (2026)

New Jersey's step therapy reform law (A1825), effective January 1, 2026, provides significant new protections for Cosentyx patients. State-regulated plans must grant step therapy overrides when specific criteria are met.

Medical Exception Criteria

Step therapy overrides are required if your prescriber determines:

  • Contraindication: The required step therapy drug is contraindicated or likely to cause adverse reactions
  • Ineffectiveness: The required drug is expected to be less effective than Cosentyx based on your clinical characteristics
  • Stability: You're already stable on Cosentyx (continuity of care protection)
  • Best Medical Interest: Step therapy is not in your best medical interest

Override Request Timeline

Request Type Response Deadline Coverage Duration
Urgent 24 hours Minimum 180 days
Non-urgent 72 hours Minimum 180 days

At Counterforce Health, we help patients and providers navigate these new protections by analyzing denial letters and crafting targeted appeals that cite specific A1825 criteria. Our platform identifies the exact denial basis and generates evidence-backed responses aligned to New Jersey's step therapy override requirements.

Turnaround Standards and Deadlines

Prior Authorization Timelines

Horizon BCBS must respond to PA requests within specific timeframes:

  • Standard requests: 15 calendar days (may extend 14 additional days if more information needed)
  • Urgent requests: 72 hours after receiving necessary information
  • Peer-to-peer consultation: Medical director must attempt contact on 2 consecutive business days

Internal Appeals Process

  • Level 1: 180 days to file from denial date
  • Level 2: 60 days to file from Level 1 decision
  • Expedited appeals: 48 hours for urgent cases
Tip: Start your appeal process early. New Jersey allows 4 months to file external appeals, but internal appeals must be completed first.

Appeals Process: Internal and External

Internal Appeals with Horizon BCBS

  1. File promptly: Submit appeals through the Horizon provider portal or member services
  2. Include comprehensive documentation: Medical records, treatment history, clinical rationale, and relevant guidelines
  3. Request expedited review if delay would jeopardize your health

External Appeals Through IHCAP

New Jersey's Independent Health Care Appeals Program provides independent review after internal appeals are exhausted.

Key Features:

  • No cost to patients (insurers pay all fees)
  • Binding decisions on insurance companies
  • Medical expert review by specialists in relevant fields
  • High success rates for well-documented cases

Timeline:

  • Preliminary review: 5 business days
  • Standard decision: 45 calendar days
  • Expedited decision: 48 hours for urgent cases

How to File:

  • Submit online through Maximus portal (verify current link)
  • Call IHCAP hotline: 1-888-393-1062
  • Required documents: denial letters, medical records, supporting literature

Continuity of Care Protections

Horizon BCBS provides continuity of care coverage during provider transitions:

Coverage Duration by Condition

  • Oncological treatment: Up to one year
  • Psychiatric treatment: Up to one year
  • Post-operative care: Up to six months
  • Active chronic conditions: 60 days (unless treatment plan changes)

Eligibility Requirements

  • Must be receiving ongoing treatment at time of enrollment or provider termination
  • Condition must be unstable, severe, or life-threatening
  • Coverage continues until condition stabilizes sufficiently for safe transfer
Note: Routine ongoing care for stable chronic conditions typically doesn't qualify for transitional coverage.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Step therapy not completed Document inadequate response or contraindications to preferred agents; cite A1825 override criteria
Not medically necessary Provide detailed medical necessity letter with clinical rationale and guideline support
Insufficient documentation Submit complete treatment history, diagnosis confirmation, and specialist evaluation
Quantity limits exceeded Justify higher dose/frequency with clinical evidence and FDA labeling
TB screening incomplete Provide required TB tests and clearance documentation

Practical Scripts and Templates

Patient Phone Script for Horizon BCBS

"Hi, I'm calling about a prior authorization denial for Cosentyx (secukinumab). My member ID is [ID number]. I'd like to understand the specific denial reason and request information about filing an appeal. Can you also tell me about New Jersey's step therapy override process under the new A1825 law?"

Clinician Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient name] regarding Cosentyx (secukinumab) denial. The patient has documented inadequate response to [list prior therapies] and meets criteria for step therapy override under New Jersey law A1825. I have clinical documentation supporting medical necessity."

From our advocates: We've seen success when providers emphasize specific clinical factors that make step therapy inappropriate—such as previous serious adverse reactions or unique patient characteristics that predict poor response to preferred agents. The key is connecting your patient's specific situation to the state's override criteria.

When to Contact State Regulators

Contact the New Jersey Department of Banking and Insurance (DOBI) when:

  • Internal appeals are denied and you need external review guidance
  • Insurance company violates state timeline requirements
  • Questions about A1825 step therapy override rights
  • Complaints about improper denial practices

DOBI Consumer Hotline: 1-800-446-7467 IHCAP Hotline: 1-888-393-1062

FAQ

Q: How long does Horizon BCBS prior authorization take in New Jersey? A: Standard requests: 72 hours for non-urgent, 24 hours for urgent cases. The clock starts when all required information is received.

Q: What if Cosentyx isn't on my formulary? A: Request a formulary exception through the standard PA process. Include medical necessity documentation and evidence that formulary alternatives are inappropriate.

Q: Can I request an expedited appeal? A: Yes, if delay would seriously jeopardize your health or functional ability. Both internal and external appeals offer expedited options.

Q: Does step therapy apply if I failed treatments outside New Jersey? A: Prior treatment failures from other states should count toward step therapy requirements. Include complete documentation from out-of-state providers.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by your insurance company. External appeals through IHCAP are reviewed by independent medical experts and are binding on the insurer.

Q: How does the new A1825 law help me? A: Starting January 1, 2026, state-regulated plans must grant step therapy overrides when your doctor determines the required drugs are inappropriate for your specific situation.

Counterforce Health transforms the complex appeals process by analyzing your specific denial and generating targeted, evidence-backed responses. Our platform helps patients, clinicians, and specialty pharmacies turn insurance denials into successful approvals by identifying the exact denial basis and crafting point-by-point rebuttals aligned to payer policies and state protections like New Jersey's A1825 step therapy reform.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurance plan and consult healthcare professionals for medical decisions.

Sources & Further Reading

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