By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (secukinumab) Covered by Cigna in New Jersey: Prior Authorization, Appeals, and Formulary Alternatives

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

Fastest path to approval: Have your rheumatologist or dermatologist submit a prior authorization request documenting trial/failure of preferred alternatives like Tremfya (guselkumab) and meet age/specialist requirements. If denied, you have 180 days for internal appeals, then external review through New Jersey's IHCAP program. First step today: Call Cigna at the number on your insurance card to verify your formulary tier and PA requirements, then schedule with a specialist if needed.

Table of Contents

Coverage Requirements at a Glance

Requirement What it means Where to find it Source
Prior Authorization Specialist must submit PA before coverage Cigna provider portal or fax Cigna PA Policy
Age Minimums ≥18 years (most conditions), ≥6 years (pediatric psoriasis), ≥4 years (hidradenitis suppurativa) PA criteria document Cigna PA Policy
Specialist Required Rheumatologist or dermatologist prescription/consultation All initial approvals Cigna PA Policy
Step Therapy Trial of preferred alternatives (e.g., Tremfya) required January 2025 formulary updates Cigna Policy Updates
Appeals Deadline 180 days from denial for internal appeals New Jersey insurance law NJ IHCAP Program

When Formulary Alternatives Make Sense

Before pursuing Cosentyx (secukinumab), it's worth understanding when Cigna's preferred alternatives might work for your condition. The insurance company requires step therapy because clinical studies show similar effectiveness across many IL-17 and IL-23 inhibitors for psoriasis and psoriatic arthritis.

Consider alternatives when:

  • You're newly diagnosed and haven't tried other biologics
  • Cost is a primary concern (preferred drugs typically have lower copays)
  • Your specialist recommends starting with a different mechanism of action
  • You have comorbidities that favor one drug over another

Push for Cosentyx when:

  • You've failed preferred alternatives with documented lack of efficacy
  • You experienced adverse reactions to step therapy drugs
  • Your specialist has clinical reasons specific to your case
  • You've been stable on Cosentyx and are switching insurance plans

Typical Cigna Alternatives to Cosentyx

Based on Cigna's 2025 formulary updates, here are the preferred alternatives you'll likely need to try first:

IL-23 Inhibitors (Preferred)

Tremfya (guselkumab) - Cigna's preferred subcutaneous option for both plaque psoriasis and psoriatic arthritis. Dosed every 8 weeks after initial loading.

Pros: Lower copay as preferred drug, proven efficacy in head-to-head studies Cons: Different injection schedule, may not work for all patients

TNF Inhibitors (Select NDCs)

Humira (adalimumab) - Specific NDCs starting with 00074 remain preferred for some plans Biosimilar alternatives - Various adalimumab biosimilars may be preferred

Pros: Extensive real-world experience, multiple indications Cons: Higher infection risk, requires TB screening, injection site reactions

IL-17 Inhibitors (Non-Preferred)

Taltz (ixekizumab), Siliq (brodalumab) - Similar mechanism to Cosentyx but typically require step therapy

From our advocates: We've seen patients successfully get Cosentyx approved after documenting specific reasons why Tremfya wasn't suitable - such as injection site reactions or scheduling conflicts with the every-8-week dosing. The key is having your specialist document these issues clearly in the PA request.

Prior Authorization: Step-by-Step Process

Step 1: Verify Coverage (Patient - Same Day)

Call the number on your Cigna insurance card and ask:

  • Is Cosentyx on my formulary?
  • What tier is it on?
  • Do I need prior authorization?
  • What's my specialty drug copay?

Step 2: Specialist Consultation (Patient - 1-2 weeks)

Schedule with a rheumatologist (for arthritis conditions) or dermatologist (for psoriasis). Cigna requires specialist involvement for all initial Cosentyx approvals.

Step 3: Document Prior Therapies (Clinic - Ongoing)

Your specialist needs records of:

  • Previous treatments tried and failed
  • Specific reasons for failure (lack of efficacy vs. adverse events)
  • Objective measures of disease activity
  • Any contraindications to preferred alternatives

Step 4: Submit PA Request (Clinic - Same Day)

Specialist submits via:

  • CoverMyMeds portal
  • Cigna provider portal
  • Fax to Express Scripts (verify current number)

Timeline: Standard review takes 5 business days; mark urgent if needed.

Step 5: Follow Up (Clinic - 3-5 days)

Track the request and be prepared to provide additional documentation if requested.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document trial/failure of Tremfya or other preferred agents Treatment dates, response measures, reasons for discontinuation
Lack of specialist involvement Ensure rheumatologist or dermatologist is prescriber Specialist consultation notes, prescription from specialist
Insufficient disease severity Provide objective measures PASI scores, joint counts, imaging results, quality of life measures
Missing prior authorization Resubmit with complete PA form Cigna PA forms
Age requirements not met Verify patient meets minimum age for indication Birth date verification, appropriate indication coding

Appeals Process in New Jersey

New Jersey offers one of the most patient-friendly appeals processes in the country through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals (Required First Step)

Timeline: 180 days from denial date Process: Submit written appeal to Cigna including:

  • Copy of denial letter
  • Medical records supporting necessity
  • Specialist letter explaining clinical rationale

External Review Through IHCAP

After completing Cigna's internal appeals (typically 2 levels), you can request external review through New Jersey's IHCAP program.

Key advantages:

  • Independent physician reviewers with appropriate specialty
  • No cost to you (insurers pay all fees)
  • Binding decision if overturned
  • Fast timeline (45 days standard, expedited available)

Contact: IHCAP hotline at 1-888-393-1062

When preparing your external appeal, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to the plan's own rules.

Formulary Exception Strategy

If Cosentyx isn't on your formulary at all, Cigna offers a formulary exception process that can provide coverage when clinical necessity is demonstrated.

Exception criteria:

  • Physician certifies formulary alternatives were detrimental, ineffective, or likely to be ineffective
  • Request supported by peer-reviewed, evidence-based literature
  • Clinical rationale specific to patient's condition

Timeline: 72 hours for standard review, 24 hours for expedited

Evidence that helps:

  • Published studies showing superior efficacy for your specific condition
  • Documentation of allergies or contraindications to formulary options
  • Specialist letter explaining why Cosentyx is uniquely appropriate

Switching Between Biologics: What to Expect

If you're transitioning from another biologic to Cosentyx, coordination between specialists is crucial.

For efficacy failure: No washout period typically needed - start Cosentyx at your next scheduled dose to avoid disease flare.

For safety concerns: Washout until adverse events resolve, typically 1 month or 3-4 half-lives of the previous drug.

Monitoring requirements:

  • Baseline labs: CBC, liver function, kidney function
  • TB screening annually
  • Regular efficacy assessments every 3-6 months

Your dermatologist and rheumatologist should coordinate care, especially if you have both psoriasis and psoriatic arthritis.

Re-trying for Cosentyx Later

If initially denied, document everything during your trial of alternative therapies:

Track objectively:

  • Disease activity scores (PASI for psoriasis, joint counts for arthritis)
  • Quality of life measures
  • Adverse events or intolerances
  • Photos of skin lesions (for psoriasis)
  • Functional assessments

Timeline for re-appeal: Most insurers allow new PA requests after 3-6 months of documented inadequate response to alternatives.

The platform offered by Counterforce Health can help analyze your specific situation and identify the strongest evidence for a successful re-appeal.

Frequently Asked Questions

How long does Cigna prior authorization take in New Jersey? Standard PA requests are reviewed within 5 business days. Urgent requests can be processed within 24-48 hours if marked appropriately.

What if Cosentyx is non-formulary on my plan? You can request a formulary exception through Cigna's process, which requires physician documentation that formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Both internal appeals and New Jersey's external review offer expedited pathways.

Does step therapy apply if I failed biologics outside New Jersey? Yes, documented failures from previous insurance plans or locations count toward step therapy requirements if properly documented.

How much will Cosentyx cost with Cigna coverage? Costs vary by plan, but specialty biologics typically fall on higher tiers. Check your specific plan's specialty drug copay or coinsurance.

What happens if my appeal is denied? In New Jersey, you can proceed to external review through IHCAP, where independent physicians make binding coverage decisions.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For additional help with insurance appeals in New Jersey, contact the NJ Department of Banking and Insurance or consider working with specialized advocacy services.

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