By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Covered by Blue Cross Blue Shield in New York: Complete PA Guide, Appeals, and Step Therapy Overrides

Answer Box: Getting Cosentyx Covered by Blue Cross Blue Shield in New York

Cosentyx (secukinumab) requires prior authorization from Blue Cross Blue Shield New York plans, with step therapy typically requiring trials of preferred biologics first. Submit PA through your provider portal with diagnosis codes, prior treatment failures, and TB screening results. If denied, you have 180 days for internal appeals and 4 months for external review through NY Department of Financial Services. First step today: Contact your dermatologist or rheumatologist to initiate the PA process and gather documentation of any failed prior therapies.

Table of Contents

Plan Types & Coverage Differences

Blue Cross Blue Shield of New York (primarily Anthem BCBS NY) offers mainly EPO plans, with limited HMO/PPO availability. Understanding your plan type affects how you access specialists and specialty drugs like Cosentyx.

Plan Type Specialist Referrals Out-of-Network Coverage Cosentyx Access
EPO (most common) No referral needed Emergency only In-network specialty pharmacy required
HMO PCP referral typically required Emergency only In-network specialty pharmacy required
PPO (limited) No referral needed Yes, higher costs In-network preferred for coverage
Note: Anthem EPO plans dominate New York's market. Verify your specific plan documents, as coverage details vary by employer group.

Formulary Status & Tier Placement

Cosentyx typically appears on Tier 2-3 (non-preferred/specialty) of Blue Cross Blue Shield New York formularies. This placement means higher copays and stricter utilization controls compared to preferred biologics.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all prescriptions Anthem NY Provider Portal
Formulary Tier Tier 2-3 (non-preferred) Plan-specific drug list
Step Therapy 1-2 preferred biologics first PA criteria documents
Quantity Limits 17 units/365 days (150mg) Plan formulary
Specialty Pharmacy CarelonRx or contracted network Member services

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Diagnosis codes (L40.0-L40.9 for psoriasis, M07.6 for PsA, M45 for AS)
    • Prior therapy records and failure documentation
    • Recent TB screening results
  2. Submit PA Request (Prescriber)
    • Use Anthem provider portal or fax
    • Include medical necessity letter
    • Timeline: 72 hours (standard) or 24 hours (urgent)
  3. Track Status (Patient/Clinic)
    • Call member services: 1-800-682-9090
    • Check provider portal for updates
    • Prepare appeal documents if needed

Clinician Corner: Medical Necessity Letter Checklist

Your medical necessity letter should include:

  • Diagnosis: Specific ICD-10 codes and disease severity
  • Prior treatments: Document failures, intolerances, or contraindications to preferred agents
  • Clinical rationale: Why Cosentyx is appropriate for this patient
  • Monitoring plan: Safety assessments and follow-up schedule

Step Therapy Rules & Exceptions

New York's step therapy reform laws, effective January 1, 2026, limit requirements to no more than two medications, each trialed for no more than 30 days unless clinically supported.

Common Step Therapy Requirements

Before Cosentyx approval, plans typically require trials of:

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Ustekinumab (Stelara)

Exception Criteria

Plans must grant step therapy exceptions when:

  • Preferred drugs are contraindicated
  • Prior therapies were ineffective or caused intolerance
  • Patient is stable on Cosentyx
  • Provider attests to medical necessity
Tip: Document any out-of-state biologic trials. New York law accepts prior therapy failures regardless of where they occurred.

Specialty Pharmacy Network

Cosentyx must be dispensed through participating specialty pharmacies due to its biologic nature and refrigeration requirements.

CarelonRx Specialty Pharmacy (Primary Network)

  • Phone: 1-833-255-0646 (24/7 support)
  • Services: Home delivery, injection training, side effect monitoring
  • Setup: Pharmacy calls after PA approval to schedule delivery

Patient Enrollment Process

  1. Activation: Call 1-844-COSENTYX after PA approval
  2. Pharmacy Contact: Expect call from specialty pharmacy
  3. Delivery Setup: Schedule home delivery or CVS pickup
  4. Support Access: 24/7 pharmacist and nurse consultation

Counterforce Health helps patients navigate complex specialty pharmacy requirements and insurance approvals. Our platform analyzes denial letters and creates targeted appeals that address specific payer criteria, potentially reducing the time to get specialty medications like Cosentyx approved.

Appeals Process for New York

New York offers robust appeal protections with specific timelines and external review options.

Internal Appeals (Level 1)

  • Deadline: 180 days from denial
  • Timeline: 30 days (standard), 72 hours (urgent)
  • Submit via: Provider portal or member services

External Review (Level 2)

  • Deadline: 4 months after final internal denial
  • Timeline: 30 days (standard), 72 hours (urgent), 24 hours (urgent drug denials)
  • Authority: NY Department of Financial Services
  • Cost: Up to $25 (waived for hardship/wins)
  • Decision: Binding on insurer

When to Request Expedited Review

  • Risk of serious deterioration
  • Functional impairment without treatment
  • Hospitalization risk
  • Rapid disease progression

Common Denial Reasons & Solutions

Denial Reason Solution Strategy
Step therapy not completed Document prior biologic failures; request exception for contraindications
Not medically necessary Submit peer-reviewed literature; specialist letter with severity metrics
Quantity limits exceeded Provide weight-based dosing rationale; cite FDA labeling
Missing TB screening Submit recent chest X-ray and interferon-gamma release assay
Age restrictions Verify FDA-approved indications (≥6 years psoriasis, ≥2 years PsA)
From our advocates: "We've seen denials overturned when providers include specific severity scores (PASI for psoriasis, DAS28 for rheumatoid conditions) and document functional impact. Numbers speak louder than general statements about disease severity."

Cost Support Options

Manufacturer Support

  • Cosentyx Copay Program: $0 copay for eligible commercially insured patients
  • Covered Until You're Covered: Free medication up to 2 years during PA process
  • Eligibility: Commercial insurance (not Medicare/Medicaid)

Additional Resources

  • Patient Advocate Foundation: Copay relief programs
  • HealthWell Foundation: Disease-specific grants
  • State pharmaceutical assistance: Check NY EPIC program for seniors

When to Escalate

Contact these New York resources if standard appeals fail:

NY Department of Financial Services

  • External Appeals: File online through DFS Portal
  • Complaints: Insurance company violations
  • Timeline violations: PA or appeal deadline breaches

Community Health Advocates

  • Phone: 888-614-5400
  • Services: Free insurance counseling and appeal assistance
  • Coverage: All New York residents

For complex cases involving multiple denials or unusual circumstances, Counterforce Health specializes in creating evidence-backed appeals that align with specific payer policies and clinical guidelines.

FAQ

How long does Blue Cross Blue Shield PA take in New York? Standard decisions in 72 hours; urgent cases in 24 hours. Complex specialty drug reviews may take up to 15 days with complete documentation.

What if Cosentyx is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Non-formulary doesn't mean uncoverable—it requires stronger justification.

Can I request an expedited appeal? Yes, if delay risks serious health deterioration. Your provider must certify medical urgency. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if I failed biologics outside New York? No, New York law accepts prior therapy failures from any state. Document out-of-state treatments in your PA submission.

What's the difference between internal and external appeals? Internal appeals are reviewed by your insurer; external appeals are reviewed by independent medical experts assigned by NY DFS. External decisions are binding.

How much will Cosentyx cost with Blue Cross Blue Shield coverage? Costs vary by plan tier and deductible status. Specialty tier medications typically have $50-$150 copays or 20-40% coinsurance. Check your specific plan documents.

Can I use retail pharmacy for Cosentyx? No, Cosentyx requires specialty pharmacy dispensing due to refrigeration and handling requirements. CVS pickup may be available through specialty pharmacy programs.

What happens if my appeal is denied? After internal denial, you can file external review with NY DFS within 4 months. External reviewers often overturn denials with proper clinical documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary by plan and employer group. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals and prior authorizations, consider consulting with advocacy services like Counterforce Health.

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