By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Covered by Blue Cross Blue Shield of Illinois: Complete Coding, PA, and Appeals Guide

Answer Box: Getting Cosentyx Approved in Illinois

Cosentyx (secukinumab) requires prior authorization through Blue Cross Blue Shield of Illinois for 2024-2025, using HCPCS code J3247 for IV formulation or J3590 for subcutaneous. Submit PA requests with proper ICD-10 codes (L40.0 for plaque psoriasis, L40.50-59 for psoriatic arthritis), tuberculosis screening results, and severity documentation. If denied, file internal appeals within 180 days, then external review through Illinois Department of Insurance within 30 days. Start today: Call BCBS member services to verify PA status and download forms from the provider portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Cosentyx Conditions
  3. Product Coding: HCPCS, J-Codes, and NDC Numbers
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification Steps with BCBS Illinois
  7. Quick Pre-Submission Audit Checklist
  8. Appeals Process for Denials
  9. FAQ: Common Questions

Coding Basics: Medical vs. Pharmacy Benefit Paths

Cosentyx coverage through Blue Cross Blue Shield of Illinois depends on the administration route and your specific plan design. Understanding which benefit applies helps ensure proper coding and faster approvals.

Medical Benefit (Provider-Administered)

  • IV formulation: Always billed under medical benefit
  • Office-administered subcutaneous: May qualify for medical benefit
  • Requires: HCPCS J-codes, CPT administration codes, place of service codes

Pharmacy Benefit (Self-Administered)

  • Home subcutaneous injections: Typically pharmacy benefit
  • Specialty pharmacy distribution: Common pathway
  • Requires: NDC codes, days supply calculations, quantity limits verification
Tip: Blue Cross Blue Shield of Illinois updated their specialty pharmacy PA requirements effective January 2025 for provider-administered therapies, expanding prior authorization requirements.

ICD-10 Mapping for Cosentyx Conditions

Accurate diagnosis coding is critical for Cosentyx approvals. Use the most specific ICD-10 code available based on clinical documentation.

Condition ICD-10 Code Documentation Requirements
Plaque psoriasis L40.0 Body surface area (BSA), PASI score, clinical photos
Psoriatic arthritis, unspecified L40.50 Joint involvement, imaging, rheumatology consultation
Distal interphalangeal PsA L40.51 Specific joint documentation, X-rays
Psoriatic arthritis mutilans L40.52 Severe deformity documentation
Psoriatic spondylitis L40.53 Spinal involvement, MRI findings
Juvenile psoriatic arthritis L40.54 Age verification, pediatric rheumatology
Ankylosing spondylitis M45.9 Separate from psoriatic conditions
Hidradenitis suppurativa L73.2 Hurley stage, lesion count

Key Documentation Words That Support Coding:

  • Severity indicators: "moderate-to-severe," "extensive," "disabling"
  • Objective measures: "PASI ≥10," "BSA >10%," "DLQI score"
  • Functional impact: "unable to work," "sleep disruption," "quality of life impairment"
Note: Avoid coding both psoriasis (L40.0) and arthritis separately when psoriatic arthritis is diagnosed. Use the L40.5- series exclusively for proper ICD-10 specificity.

Product Coding: HCPCS, J-Codes, and NDC Numbers

HCPCS J-Code for Cosentyx

J3247 - Injection, secukinumab, intravenous, 1 mg (effective July 1, 2024)

  • Billing units: 1 unit = 1 mg
  • Standard dose: 125 mg = 125 billing units
  • Replaces: Previous miscellaneous codes J3590, C9399

NDC Numbers and Package Information

NDC Code Product Package Size Billing Units
00078-1168-61 Cosentyx IV Solution 125 mg/5 mL 125 units

Administration Coding

For IV administration, pair with appropriate CPT codes:

  • 96413: Chemotherapy administration, IV infusion, initial, up to 1 hour
  • 96415: Each additional hour (if applicable)

For subcutaneous administration:

  • Often billed under pharmacy benefit or as buy-and-bill
  • May use J3590 (unclassified injection) pending specific J-code assignment
Important: Medicare ASP pricing for J3247 is $17.8125 per mg unit, with 20% coinsurance approximately $3.57 per unit.

Clean Prior Authorization Request Anatomy

A complete PA request for Cosentyx through BCBS Illinois should include these elements:

Patient Information Section

  • Member ID and group number
  • Primary diagnosis with specific ICD-10 code
  • Prescribing provider NPI and specialty
  • Requested medication with NDC or J-code

Clinical Justification

  • Disease severity documentation:
    • PASI score ≥10 (psoriasis)
    • BSA involvement >10%
    • DLQI score ≥10
    • Joint count and imaging (psoriatic arthritis)
  • Prior therapy documentation:
    • Methotrexate trial and outcome
    • TNF inhibitor history (if applicable)
    • Contraindications to preferred agents
    • Dates and dosages of previous treatments

Safety Requirements

  • Tuberculosis screening:
    • TST or IGRA results (within 12 months)
    • Chest X-ray report
    • Treatment of latent TB if positive

Dosing and Administration Plan

  • Proposed regimen: Loading dose followed by maintenance
  • Site of care: Office, infusion center, or home
  • Duration of therapy: Initial approval period requested
From our advocates: We consistently see faster approvals when providers submit complete packets upfront rather than responding to information requests. Include all severity documentation and prior therapy details in the initial submission to avoid 7-10 day delays for additional information.

Frequent Coding and Billing Pitfalls

Unit Conversion Errors

  • Mistake: Billing 1 unit for 125 mg dose
  • Correct: Bill 125 units for 125 mg (1 mg = 1 unit for J3247)

Mismatched Diagnosis Codes

  • Mistake: Using L40.9 (unspecified psoriasis) for all cases
  • Correct: Use most specific code available (L40.0 for plaque psoriasis)

Missing Administration Codes

  • Mistake: Billing J3247 without CPT administration code
  • Correct: Include 96413 for IV infusion administration

Incorrect Benefit Determination

  • Mistake: Assuming all Cosentyx is pharmacy benefit
  • Correct: Verify medical vs. pharmacy benefit based on administration route

Date of Service Issues

  • Mistake: Missing or incorrect administration dates
  • Correct: Ensure date of service matches actual administration

Verification Steps with BCBS Illinois

Before submitting any Cosentyx request, verify these key elements:

Step 1: Benefit Verification

Step 2: Formulary Status Check

  • Review current Performance Select Drug List
  • Confirm tier placement
  • Identify step therapy requirements
  • Note any formulary exceptions needed

Step 3: Provider Network Status

  • Verify prescribing provider is in-network
  • Confirm administration site is covered
  • Check specialty pharmacy network requirements

Step 4: Prior Authorization Portal Access

  • Confirm provider portal access
  • Download current PA forms
  • Review submission requirements and timelines

Contact Information for Verification:

  • Provider Services: 1-800-344-8527
  • Member Services: Number on member ID card
  • Carelon (UM vendor): 866-455-8415

Quick Pre-Submission Audit Checklist

Use this checklist before submitting any Cosentyx request to BCBS Illinois:

Documentation Complete ✓

  • Member ID and group number verified
  • Specific ICD-10 diagnosis code included
  • Prescriber NPI and specialty confirmed
  • Correct HCPCS/J-code selected

Clinical Requirements ✓

  • Disease severity scores documented (PASI, BSA, DLQI)
  • Prior therapy history with dates and outcomes
  • TB screening results (TST/IGRA + chest X-ray)
  • Contraindications to preferred agents noted

Coding Accuracy ✓

  • Billing units calculated correctly (mg to units)
  • Administration CPT codes included if applicable
  • Place of service code appropriate
  • Date of service accurate

Submission Method ✓

  • Correct portal or fax number used
  • All required attachments included
  • Expedited request marked if urgent
  • Follow-up timeline noted

Appeals Process for Denials

When BCBS Illinois denies Cosentyx coverage, you have specific rights and timelines under Illinois law.

Internal Appeal Process

Timeline: File within 180 days of denial notice Decision: 15 business days (standard), 72 hours (expedited)

Submission Methods:

  • Mail: Blue Cross Community Health Plans, Attn: Grievance and Appeals Dept., PO Box 660717, Dallas, TX 75266
  • Standard Fax: 1-866-643-7069
  • Expedited Fax: 1-800-338-2227
  • Phone: Member Services number on ID card

External Review Process

If your internal appeal is denied, Illinois residents can request external review through the Illinois Department of Insurance.

Critical Timeline: Must file within 30 calendar days of final internal denial (shorter than most states)

Contact Information:

  • Phone: 877-527-9431
  • Email: [email protected]
  • Address: 320 W. Washington Street, Springfield, IL 62767

External Review Features:

  • Independent Review Organization (IRO) assigns board-certified specialist
  • Decision within 15-45 business days (72 hours for urgent cases)
  • No cost to patient
  • Decision is binding on BCBS Illinois
Tip: Illinois also offers help through the Attorney General's Health Care Helpline at 1-877-305-5145 for complex insurance problems.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules. For complex cases like Cosentyx denials involving step therapy or medical necessity challenges, we help clinicians and patients build stronger appeals with the right evidence and procedural requirements. Visit www.counterforcehealth.org to learn more about our appeal assistance services.

FAQ: Common Questions

Q: How long does BCBS Illinois prior authorization take for Cosentyx? A: Standard PA decisions are made within 5-10 business days. Expedited requests (when delay would jeopardize health) are processed within 72 hours.

Q: What if Cosentyx is non-formulary on my BCBS Illinois plan? A: You can request a formulary exception by demonstrating medical necessity and failure/contraindication to preferred alternatives. Include clinical documentation supporting why Cosentyx is medically necessary.

Q: Can I request an expedited appeal if my Cosentyx is denied? A: Yes, if a delay in treatment would seriously jeopardize your health or ability to regain maximum function. Mark your appeal as "expedited" and provide supporting clinical documentation.

Q: Does step therapy apply if I've already failed TNF inhibitors in another state? A: Previous therapy failures should count regardless of where they occurred. Include complete medical records and provider documentation of prior treatments and outcomes.

Q: What's the difference between medical and pharmacy benefit for Cosentyx? A: IV formulations are typically covered under medical benefit (using J-codes), while self-administered subcutaneous injections may be covered under pharmacy benefit (using NDC codes). Your specific plan design determines coverage.

Q: How do I find out if my provider is in-network for Cosentyx administration? A: Use the BCBS Illinois provider directory online or call member services. For specialty infusion centers, verify both the facility and the administering physician are in-network.

Q: What happens if I miss the 30-day deadline for external review in Illinois? A: The 30-day deadline is strict under Illinois law. However, you may still have options through the Illinois Attorney General's office or by filing a complaint with the Department of Insurance for procedural violations.

Q: Can I appeal a quantity limit denial for Cosentyx? A: Yes, you can request a quantity limit exception by providing clinical documentation that the standard quantity is insufficient for your medical condition. Include dosing rationale and response data.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Blue Cross Blue Shield of Illinois and consult with your healthcare provider regarding treatment decisions. For personalized assistance with complex appeals, consider working with advocacy services like Counterforce Health that specialize in insurance coverage challenges.

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