By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Blue Cross Blue Shield in Pennsylvania: Complete Appeals Guide

Answer Box: Getting Cosentyx Covered by Blue Cross Blue Shield in Pennsylvania

Cosentyx (secukinumab) requires prior authorization from all Blue Cross Blue Shield plans in Pennsylvania, with step therapy requirements effective January 2025. The fastest path to approval: (1) Document failed trials with preferred agents like methotrexate or TNF inhibitors, (2) Submit complete PA forms with tuberculosis screening and psoriasis severity scores (PASI ≥10, BSA ≥10%), and (3) If denied, use Pennsylvania's new external review program, which overturns 50% of denials. Start by calling your BCBS plan's provider services to confirm current PA requirements and submission portals.

Table of Contents

What Affects Cosentyx Approval Timing

Several factors determine how quickly Blue Cross Blue Shield will approve your Cosentyx prior authorization in Pennsylvania:

Benefit Type & Plan Complexity

  • Commercial plans (Independence Blue Cross, Capital Blue Cross): Standard 14-day review timeline
  • Medicare Advantage: May require additional CMS compliance checks
  • Medicaid managed care: Often involves state-specific formulary reviews

Documentation Completeness The most common cause of delays is incomplete initial submissions. BCBS requires:

  • Tuberculosis screening results (TST/IGRA and chest X-ray documentation)
  • Psoriasis severity scores: PASI ≥10, BSA ≥10%, DLQI ≥10
  • Step therapy documentation showing inadequate response to preferred agents
  • ICD-10 diagnosis codes and treatment history

Step Therapy Requirements As of January 2025, BCBS plans in Pennsylvania require step therapy with these preferred agents before approving Cosentyx:

  • Methotrexate
  • Cyclosporine
  • TNF inhibitors (Humira, Enbrel)
Note: If you have contraindications to preferred agents or documented treatment failures, include detailed clinical notes explaining why step therapy should be waived.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist:

  • Current insurance card and member ID
  • Prescriber information and NPI number
  • ICD-10 diagnosis codes (L40.0 for plaque psoriasis)
  • TB screening: TST/IGRA results and chest X-ray report
  • Psoriasis severity documentation: PASI, BSA, DLQI scores
  • Prior therapy records showing inadequate response or intolerance
  • Current clinical notes from dermatologist
  • Lab results if relevant (CBC, liver function tests)

Step Therapy Documentation Requirements: Document each preferred agent trial with:

  • Drug name, dose, and duration of trial
  • Reason for discontinuation (lack of efficacy, adverse effects, contraindication)
  • Clinical notes supporting the failure or intolerance
  • Dates of treatment attempts

Verification Steps:

  1. Confirm your specific BCBS plan's current formulary status for Cosentyx
  2. Check if your plan uses Availity, Carelon, or another PA portal
  3. Verify your dermatologist is in-network and authorized to prescribe

Submission to Initial Review (1-14 Days)

Pennsylvania Regulatory Timeline: BCBS plans in Pennsylvania must respond to prior authorization requests within 14 calendar days for routine cases and 72 hours for urgent medical necessity cases, per state insurance regulations.

What Reviewers Check First:

  1. Member eligibility and active coverage
  2. Prescriber credentials (must be dermatologist or in consultation with one)
  3. Step therapy compliance or valid exception criteria
  4. Medical necessity documentation including severity scores
  5. Safety screening (TB status, contraindications)

Submission Portals by Plan:

  • Independence Blue Cross: Submit via provider portal or designated fax line
  • Capital Blue Cross: Use Availity or plan-specific PA system
  • Highmark Blue Shield: Submit through provider portal or fax (verify current contact)
Tip: Mark urgent requests clearly if waiting could worsen the patient's condition. Include prescriber certification of medical urgency.

Additional Information Requests

If BCBS requests additional information, you typically have 15 business days to respond. Common requests include:

Clinical Clarifications:

  • More detailed treatment history
  • Updated severity assessments
  • Specialist consultation notes
  • Laboratory monitoring results

Administrative Updates:

  • Corrected diagnosis codes
  • Updated prescriber information
  • Member demographic changes

How to Respond Quickly:

  • Use the same submission method as your original request
  • Reference the original PA request number
  • Submit complete documentation packages rather than piecemeal responses
  • Follow up within 2-3 business days to confirm receipt

Counterforce Health's platform can help streamline this process by automatically identifying missing documentation requirements and generating comprehensive appeal packages that address common BCBS review criteria.

Decision Timeline & Outcomes

Typical Approval Timeline:

  • Day 1-3: Initial administrative review
  • Day 4-10: Clinical review and step therapy verification
  • Day 11-14: Final determination and notification

Reading Your Approval Letter: Approved requests will specify:

  • Authorized quantity and duration
  • ICD-10 codes covered
  • Any quantity limits or site-of-care restrictions
  • Renewal requirements and timing

Partial Approvals: BCBS may approve Cosentyx with modifications:

  • Reduced quantity limits
  • Shorter authorization periods
  • Required specialty pharmacy dispensing
  • Additional monitoring requirements

If Denied: Pennsylvania Appeals Process

Pennsylvania offers one of the strongest patient appeal processes in the nation. Here's your step-by-step guide:

Level 1: Internal Appeal with BCBS

  • Timeline: Must be filed within 180 days of denial
  • Decision deadline: BCBS has 30 days for standard appeals, 72 hours for urgent appeals
  • Required documents: Original denial letter, medical records, prescriber statement

Level 2: Pennsylvania Independent External Review If your internal appeal is denied, Pennsylvania's new external review program offers significant advantages:

  • Success rate: 50% of appeals are overturned in favor of patients
  • Timeline: Must be requested within 4 months of final denial
  • Cost: Free to patients
  • Decision timeframe: 45 days for standard review, 72 hours for urgent cases

How to File External Review:

  1. Visit pa.gov/reviewmyclaim
  2. Submit online or mail/fax required forms
  3. Include all supporting documentation
  4. Request expedited review if medically urgent

Free Legal Help: The Pennsylvania Health Law Project provides free assistance with specialty drug appeals:

  • Helpline: 1-800-274-3258
  • Email: [email protected]
  • Services include appeal preparation, documentation review, and hearing representation

Renewal Cycles & Ongoing Authorization

Standard Renewal Timeline: Most BCBS plans authorize Cosentyx for 6-12 months initially, then require reauthorization.

Renewal Documentation:

  • Updated clinical assessment
  • Treatment response documentation
  • Continued medical necessity justification
  • Any adverse events or dose adjustments

Streamlined Renewals: If you're stable on therapy, renewals are typically faster:

  • 5-7 business days for continuing patients
  • Less extensive documentation required
  • Focus on treatment response and safety monitoring

What Changes Speed Renewals:

  • Consistent prescriber and pharmacy
  • No dose changes or adverse events
  • Up-to-date clinical notes in system
  • Proactive submission 30 days before expiration

Timeline Visual & Milestones

Phase Timeline Key Activities Success Factors
Preparation 0-2 days Gather documents, verify requirements Complete step therapy documentation
Submission Day 1 Submit PA request via portal/fax Include all required elements
Initial Review Days 1-5 Administrative and clinical screening Clear medical necessity rationale
Additional Info Days 6-10 Respond to requests for clarification Quick, complete responses
Final Decision Days 11-14 Approval/denial notification Appeal immediately if denied
Appeal (if needed) Days 15-45 Internal appeal process Comprehensive clinical documentation
External Review Days 46-90 Independent medical review Strong evidence-based arguments

Time-Saving Tips for Faster Approval

Portal Best Practices:

  • Use electronic submission when available
  • Submit during business hours for faster processing
  • Save confirmation numbers and track submission status

Documentation Bundling: Submit all required documents together:

  • Clinical notes with severity scores
  • Prior therapy documentation
  • TB screening results
  • Prescriber attestation letter

Direct Specialty Routing:

  • Ensure requests go to appropriate clinical reviewers
  • Include specialty-specific diagnosis codes
  • Reference relevant treatment guidelines

Proactive Communication:

  • Call BCBS provider services to verify receipt
  • Follow up on pending requests after 7 business days
  • Maintain direct contact with assigned case manager
From our advocates: We've seen the fastest approvals when providers submit a comprehensive package upfront rather than responding to multiple information requests. One dermatology practice reduced their average approval time from 18 days to 8 days by creating standardized documentation bundles that address all common BCBS requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not met Document failed trials or contraindications Detailed treatment history, adverse event reports
Insufficient severity Submit updated PASI/BSA/DLQI scores Recent clinical assessment, photographs if appropriate
Missing TB screening Complete and submit screening results TST/IGRA results, chest X-ray report
Non-formulary status Request formulary exception Medical necessity letter, alternative therapy failures
Quantity limits exceeded Justify higher dose/frequency Clinical rationale, dosing guidelines, treatment response

Pennsylvania External Review Success

Pennsylvania's Independent External Review program has achieved remarkable results for patients:

2024 Performance Data:

  • 517 appeals filed in the program's first year
  • 259 successful overturns (50% success rate)
  • Average review time: 45 days for standard cases
  • No cost to patients for the review process

Why External Review Works:

  • Independent medical experts review cases
  • Focus on medical necessity rather than cost containment
  • State oversight ensures fair process
  • Binding decisions that insurers must follow

When to Request External Review:

  • Internal appeals have been exhausted
  • Strong clinical evidence supports medical necessity
  • Treatment delay could worsen condition
  • Alternative therapies have failed or are contraindicated

Counterforce Health can assist in preparing comprehensive external review submissions that leverage Pennsylvania's patient-friendly appeal environment and high success rates.

FAQ

How long does BCBS prior authorization take in Pennsylvania? Standard prior authorization decisions are made within 14 calendar days. Urgent requests are processed within 72 hours. Complete documentation submissions typically receive faster decisions.

What if Cosentyx is non-formulary on my BCBS plan? You can request a formulary exception by demonstrating medical necessity and documenting failures or contraindications to formulary alternatives. Include detailed clinical justification and supporting literature.

Can I request an expedited appeal in Pennsylvania? Yes, if waiting for standard review could seriously jeopardize your health. Your prescriber must certify the urgent medical necessity, and decisions are made within 72 hours.

Does step therapy apply if I tried medications outside Pennsylvania? Yes, documented treatment failures from other states are generally accepted. Ensure you have complete medical records and clinical notes detailing the outcomes of prior therapies.

What happens if my external review is successful? BCBS must immediately provide coverage for the treatment, including retroactive coverage if you paid out-of-pocket during the appeal process.

How much does Cosentyx cost without insurance? Cosentyx is a specialty biologic with significant costs. Manufacturer copay assistance may be available for eligible patients, and patient assistance programs exist for those who qualify.

Can I get help preparing my appeal? Yes, the Pennsylvania Health Law Project (1-800-274-3258) provides free assistance with specialty drug appeals, including preparation of documentation and representation in hearings.

What if my dermatologist isn't in-network with BCBS? You may need to obtain a referral to an in-network specialist or request an out-of-network exception if no appropriate in-network providers are available in your area.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific denial basis, then drafts targeted rebuttals aligned with each payer's requirements. For medications like Cosentyx, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Prior authorization requirements and appeal processes may vary by specific plan and change over time. Always consult with your healthcare provider about treatment decisions and verify current requirements with your insurance plan. For personalized assistance with appeals, contact the Pennsylvania Health Law Project or consult with a qualified healthcare advocate.

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