By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Covered by Cigna in Georgia: Complete 2025 Guide with Forms and Appeals

Answer Box: Getting Cosentyx (secukinumab) Covered by Cigna in Georgia

Fastest path to approval: Have your dermatologist or rheumatologist submit a complete prior authorization with documented step therapy failures and TB screening. Cigna typically decides within 72 hours for standard requests.

Three essential steps:

  1. Confirm your Cigna plan covers Cosentyx on the specialty tier (usually requires prior authorization)
  2. Gather documentation of failed conventional treatments (methotrexate, TNF inhibitors)
  3. Submit PA through Cigna provider portal or fax with complete clinical records

If denied in Georgia: You have 60 days to request external review through the Georgia Department of Insurance after exhausting internal appeals.

Table of Contents

  1. Cigna Plan Types and Coverage Differences
  2. Cosentyx Formulary Status and Tier Placement
  3. Prior Authorization Requirements
  4. Step Therapy and Quantity Limits
  5. Specialty Pharmacy Setup with Accredo
  6. Cost Sharing and Financial Assistance
  7. Submission Process and Required Forms
  8. Appeals Process in Georgia
  9. Common Denial Reasons and Solutions
  10. FAQ

Cigna Plan Types and Coverage Differences

Your Cigna plan type affects how you access specialists and where you can receive treatment, but Cosentyx coverage rules remain consistent across HMO, PPO, and EPO plans.

Referral Requirements for Specialists

Plan Type PCP Required Dermatology/Rheumatology Referrals Out-of-Network Coverage
HMO Often yes May require PCP referral No (except emergencies)
PPO No No referrals needed Yes (higher cost-share)
EPO Varies No referrals needed No (except emergencies)
Tip: Check your Cigna ID card for plan type. If it says "HMO," contact your PCP before scheduling dermatology or rheumatology appointments to confirm if a referral is needed.

For Cosentyx treatment, ensure your prescribing specialist is in-network. PPO members have out-of-network options but face higher costs and potential balance billing.

Cosentyx Formulary Status and Tier Placement

Cosentyx appears on Cigna's specialty formularies as a Tier 4 or Tier 5 medication with prior authorization requirements. The exact tier depends on your specific plan.

2024 Formulary Coverage

  • Commercial Plans: Specialty tier with 20-50% coinsurance
  • Medicare Part D: Typically Tier 5 with ~31% coinsurance after deductible
  • Prior Authorization: Required for all formulations (subcutaneous and IV)
  • Step Therapy: Must try conventional treatments and often preferred biologics first

Cigna explicitly states you cannot request a lower cost-sharing tier for specialty medications like Cosentyx through formulary exceptions.

Note: Use Cigna's online formulary search tool to confirm Cosentyx's status on your specific plan. The drug list name appears on your insurance card or plan documents.

Prior Authorization Requirements

Cigna requires comprehensive documentation for Cosentyx approval under their CNF_432 policy for subcutaneous formulations and separate policies for IV use.

Core PA Criteria

Diagnosis Requirements:

  • FDA-approved indication (plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, etc.)
  • ICD-10 code documentation (L40.0 for plaque psoriasis, L40.5x for psoriatic arthritis)
  • Disease severity metrics (PASI ≥10 or BSA ≥10% for psoriasis; objective inflammation for arthritis)

Prescriber Requirements:

  • Dermatologist or rheumatologist must prescribe or provide consultation
  • Specialist documentation of medical necessity

Safety Screening:

  • Negative TB test (QuantiFERON-TB Gold or TST) within 6-12 months
  • Chest X-ray if TB history exists
  • Hepatitis B/C screening per standard biologic protocols

Clinical Documentation Checklist

✓ Complete medical history with diagnosis confirmation
✓ Prior treatment failures with specific drugs, doses, dates, and outcomes
✓ Current disease severity assessment (PASI, BSA, joint counts, inflammatory markers)
✓ TB screening results and safety labs
✓ Medical necessity letter explaining why Cosentyx is appropriate

Step Therapy and Quantity Limits

Cigna's Preferred Specialty Management (PSM) policy requires trying less expensive treatments before approving Cosentyx.

Typical Step Therapy Requirements

For Plaque Psoriasis:

  1. At least one conventional systemic agent (methotrexate, cyclosporine, acitretin) for ≥3 months
  2. Often one preferred TNF inhibitor (adalimumab, etanercept, infliximab biosimilars)
  3. Documentation of inadequate response, intolerance, or contraindication

For Psoriatic Arthritis:

  1. At least one conventional DMARD (typically methotrexate)
  2. At least one TNF inhibitor trial
  3. Objective evidence of ongoing inflammation (elevated CRP, imaging findings)

Quantity Limits

Cigna enforces FDA-label dosing through their Drug Quantity Management policy:

  • Loading doses: 150 mg at weeks 0, 1, 2, 3, and 4
  • Maintenance: 150 mg every 4 weeks thereafter
  • Higher doses require additional justification

Specialty Pharmacy Setup with Accredo

Most Cigna plans require Cosentyx to be dispensed through Accredo, Cigna's preferred specialty pharmacy partner.

Enrollment Process

Step 1: Prescriber Referral Your doctor completes an Accredo Prescription & Enrollment Form including:

  • Patient demographics and insurance information
  • Clinical details (ICD-10, weight, allergies, concurrent medications)
  • Cosentyx prescription with strength and directions
  • Front and back copies of insurance cards

Step 2: Insurance Verification Accredo confirms coverage and processes prior authorization if not already completed.

Step 3: Patient Onboarding Accredo contacts you to:

  • Verify shipping address and delivery preferences
  • Discuss costs and copay assistance options
  • Provide injection training and clinical counseling
  • Schedule first shipment

Managing Your Account

Access your prescriptions through:

  • myCigna.com → Prescriptions → My Medications (automatically connects to Accredo)
  • Accredo.com using your prescription number
  • Mobile apps for shipment tracking and refill management

Cost Sharing and Financial Assistance

Cosentyx costs vary significantly based on your plan design and whether you've met annual deductibles.

Typical Cost Structure

List Price (2026): $8,492.03 per month for self-injectable formulations

Cigna Cost-Sharing Examples:

  • Medicare Part D: 31% coinsurance after deductible (varies by plan)
  • Commercial Plans: 20-50% coinsurance depending on specialty tier
  • High-Deductible Plans: 100% until deductible met, then coinsurance applies

Financial Assistance Options

For Commercial Insurance:

  • Cosentyx Copay Program: Eligible patients may pay $0 per month (84% of program users pay nothing)
  • Cannot be used with Medicare or other government insurance

For All Patients:

  • Novartis Patient Assistance Foundation for qualifying low-income patients
  • Direct-pay pricing: $3,674.44 per dose (55% off list price) if bypassing insurance
Important: If your commercial plan has copay accumulators or maximizers, manufacturer assistance may not count toward your deductible or out-of-pocket maximum.

Submission Process and Required Forms

Cigna Prior Authorization Forms

Subcutaneous Cosentyx:

  • Complete Cigna's "Cosentyx Subcutaneous Prior Authorization Form"
  • Available through Cigna provider portal or member services

Intravenous Cosentyx:

  • Separate "Cosentyx Intravenous Prior Authorization" form required
  • Covered under medical benefit with different criteria

Submission Methods

  1. Provider Portal: Log into Cigna's provider portal for electronic submission
  2. Fax: Submit completed forms with attachments (verify current fax numbers with Cigna)
  3. Phone: Call for urgent/expedited requests

Required Attachments

  • Chart notes from last 3-6 months
  • Lab results (TB screening, inflammatory markers, liver function)
  • Documentation of prior treatment failures
  • Medical necessity letter from prescribing specialist

Timeline: Standard PA decisions within 72 hours; expedited requests within 24 hours when delay risks health.

Appeals Process in Georgia

Georgia provides robust appeal rights through state law and the Georgia Department of Insurance.

Internal Appeals with Cigna

First-Level Internal Appeal:

  • File within 180 days of denial
  • Submit additional clinical documentation
  • Decision typically within 30 days (72 hours for urgent)

Second-Level Internal Appeal:

  • Available if first appeal denied
  • May request peer-to-peer review with medical director
  • Include updated medical necessity letter and guideline references

External Review in Georgia

Eligibility: After exhausting internal appeals for medical necessity denials

Timeline: Must file within 60 days of Cigna's final internal denial

Process:

  1. Submit application to Georgia Department of Insurance
  2. DOI assigns independent review organization
  3. Decision within 30 business days (72 hours for expedited)
  4. Free for consumers

Contact: Georgia DOI Consumer Services at 1-800-656-2298

Critical: Georgia's 60-day deadline is strict. Don't wait—file external review promptly after receiving Cigna's final denial.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not met Document failed prior treatments Complete medication history with dates, doses, outcomes
Insufficient severity Provide objective measures PASI scores, BSA, inflammatory markers, imaging
Missing TB screening Submit current test results QuantiFERON-TB Gold or TST within 6-12 months
Non-specialist prescriber Get specialist consultation Dermatologist/rheumatologist evaluation and recommendation
Quantity limit exceeded Justify higher dosing Clinical rationale for off-label dosing with literature support

Scripts for Common Situations

Calling Cigna for PA Status: "I'm calling to check the status of a prior authorization for Cosentyx submitted for [patient name], member ID [number]. Can you tell me if additional information is needed and the expected decision timeline?"

Requesting Expedited Review: "This patient has severe psoriasis/psoriatic arthritis causing significant functional impairment. A delay in treatment approval poses serious health risks. I'm requesting expedited review under your urgent criteria."

From Our Advocates

We've seen many Georgia patients successfully obtain Cosentyx coverage after initial denials by submitting comprehensive appeals with detailed treatment histories and specialist letters. The key is documenting each step therapy requirement and clearly explaining why alternatives aren't appropriate for the specific patient's condition.

FAQ

Q: How long does Cigna prior authorization take in Georgia? A: Standard requests: 72 hours. Expedited requests when delay risks health: 24 hours. Complex cases may take longer if additional information is requested.

Q: What if Cosentyx isn't on my Cigna formulary? A: You can request a formulary exception, but specialty tier drugs rarely get moved to lower-cost tiers. Focus on demonstrating medical necessity and step therapy compliance.

Q: Can I get Cosentyx covered if I haven't tried methotrexate? A: Possibly, if you have documented contraindications (liver disease, pregnancy plans, etc.). Your specialist must provide clinical justification for skipping step therapy.

Q: Does my HMO referral affect Cosentyx coverage? A: Referral requirements affect specialist access but don't change drug coverage criteria. Ensure your dermatologist/rheumatologist is in-network regardless of plan type.

Q: What happens if I move from another state to Georgia? A: Treatment history from other states counts toward step therapy requirements. Gather complete records from previous providers to avoid repeating failed treatments.

Q: Can I appeal if Cigna requires IV instead of subcutaneous Cosentyx? A: Yes. Different formulations have separate coverage policies. Your doctor should justify why the preferred formulation is medically necessary for your specific situation.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by creating evidence-backed, payer-specific submissions. Our platform analyzes denial letters, plan policies, and clinical notes to draft targeted rebuttals that address each insurer's specific requirements. For complex cases like Cosentyx appeals, having the right documentation and strategy can make the difference between approval and continued denials.

If you're facing challenges with your Cosentyx prior authorization or appeal, remember that Georgia's external review process provides a powerful second opinion from independent medical experts. Many patients have successfully overturned wrongful denials by utilizing this free state resource with proper documentation and clinical support.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult your healthcare provider about treatment options and work with your insurer for coverage determinations. For personalized assistance with Georgia insurance appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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