Answer Box: Getting Cosentyx Covered by Cigna in Texas

To get Cosentyx (secukinumab) covered by Cigna in Texas, you need: (1) specialist prescriber (dermatologist/rheumatologist), (2) prior authorization with TB screening results, and (3) documentation of failed step therapy or medical exceptions. First step today: Have your doctor order QuantiFERON-TB Gold and gather records of previous biologics tried. Submit PA via Cigna provider portal within 72 hours for standard review.

Table of Contents

1. Cigna's Coverage Policy for Cosentyx in Texas
2. Prior Authorization Requirements
3. Step Therapy and Medical Exceptions
4. Required Laboratory and TB Screening
5. Site of Care and Specialty Pharmacy Rules
6. Medical Necessity Documentation
7. Appeals Process in Texas
8. Common Denial Reasons and Solutions
9. Cost Savings and Patient Support
10. FAQ

Policy Overview

Cigna covers Cosentyx (secukinumab) under its Inflammatory Conditions Prior Authorization Policy for FDA-approved indications including plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, and hidradenitis suppurativa.

Plan Types and Coverage

• Commercial plans: Prior authorization required; often includes step therapy to TNF inhibitors
• Medicare plans: Coverage through Premier Access formulary with PA and step therapy requirements
• Specialty pharmacy: Self-injectable forms typically dispensed through Express Scripts/Accredo

Note: Texas law provides strong appeal rights through the Texas Department of Insurance external review process after internal appeals are exhausted.

Prior Authorization Requirements

Core PA Criteria

All Cosentyx approvals require:

1. Specialist prescriber: Dermatologist, rheumatologist, or gastroenterologist
2. Age requirements: ≥18 years for most indications; pediatric psoriasis ≥6 years
3. Diagnosis confirmation: ICD-10 codes and clinical documentation
4. Initial approval: 3-6 months depending on indication
5. Continuation approval: 1 year after demonstrating clinical benefit

Coverage at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Required for all formulations	PA form submission	Cigna Policy
Specialist Prescriber	Dermatology/rheumatology required	Provider credentials	PA Criteria
TB Screening	QuantiFERON or TST within 6-12 months	Lab results	Safety Requirements
Step Therapy	TNF inhibitor trial often required	Treatment history	Premier Access Criteria

Step Therapy and Medical Exceptions

Required Prior Treatments

Cigna's 2024 Premier Access criteria often require trial and failure of:

• Traditional systemic agents (≥3 months): methotrexate, cyclosporine, acitretin
• Preferred TNF inhibitors: adalimumab (Humira), etanercept (Enbrel), infliximab products

Medical Exception Pathways

You can bypass step therapy if you document:

1. Contraindications to preferred agents
2. Previous adverse events or intolerance
3. Clinical characteristics making preferred drugs inappropriate
4. Current stability on Cosentyx (for renewals)

Tip: Include specific drug names, doses, dates, and documented adverse events in your exception request.

Required Laboratory and TB Screening

Mandatory TB Testing

Before starting Cosentyx, obtain:

• QuantiFERON-TB Gold or tuberculin skin test (TST) within 6-12 months
• Chest X-ray if TB test is positive or patient has TB history
• Documentation of latent TB treatment completion if applicable

Additional Lab Requirements

Common requirements include:

• Complete blood count (CBC)
• Liver function tests
• C-reactive protein (CRP) for inflammatory arthritis
• Hepatitis B/C screening (clinical best practice)

Documentation Checklist

• TB test results (QuantiFERON or TST)
• Chest X-ray report (if indicated)
• Baseline labs (CBC, LFTs)
• Inflammatory markers (CRP, ESR for arthritis)
• Imaging studies (MRI for axial spondyloarthritis)

Site of Care and Specialty Pharmacy Rules

Self-Injectable Cosentyx

• Pharmacy benefit: Covered through prescription drug plan
• Specialty pharmacy: Must use Express Scripts/Accredo or designated provider
• Home administration: Allowed after initial training
• 30-day supply limit: Standard for specialty medications

IV Cosentyx (if applicable)

• Medical benefit: Covered under medical insurance
• Site of care restrictions: May prefer outpatient infusion centers over hospital
• Prior authorization: Separate process from self-injectable form

Medical Necessity Documentation

Essential Elements for PA Success

Your medical necessity letter should include:

1. Patient identification: Name, DOB, Cigna member ID
2. Diagnosis and severity:
   • ICD-10 codes (L40.0 for plaque psoriasis)
   • PASI score ≥10 or BSA ≥10% for psoriasis
   • Objective inflammation markers for arthritis
3. Treatment history:
   • Previous therapies with dates, doses, duration
   • Specific reasons for discontinuation
   • Documentation of inadequate response or adverse events
4. Clinical rationale:
   • Why Cosentyx is medically necessary
   • Reference to FDA labeling or guidelines
   • Patient-specific factors supporting choice

Sample Medical Necessity Narrative

"Patient has moderate-to-severe plaque psoriasis (PASI 15, BSA 20%) with inadequate response to methotrexate 25mg weekly for 6 months (PASI improved only to 12). Adalimumab 40mg every other week was discontinued after 4 months due to injection site reactions and secondary loss of efficacy. Cosentyx is medically necessary based on FDA labeling for moderate-to-severe psoriasis and patient's contraindication to additional TNF inhibitors."

Appeals Process in Texas

Internal Appeals

If your initial PA is denied:

1. Timeline: File within 180 days of denial
2. Standard review: 60 days for decision
3. Expedited review: 72 hours if delay could jeopardize health
4. Required elements: Denial letter, additional clinical evidence, prescriber support

External Review Through Texas DOI

After exhausting internal appeals:

1. Eligibility: Denials based on medical necessity, appropriateness, or experimental status
2. Timeline: Request within 4 months of final internal denial
3. Process: Independent Review Organization (IRO) review
4. Cost: Free to patient; insurer pays IRO fees
5. Decision timeline: 20 days standard, 5 days expedited

Texas Resources for Help

• Texas Department of Insurance: 1-800-252-3439
• Office of Public Insurance Counsel: 1-877-611-6742
• IRO Information Line: 1-866-554-4926

When working with patients who need specialty medications like Cosentyx, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals. The 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, pulling the right citations from FDA labeling, peer-reviewed studies, and specialty guidelines.

Common Denial Reasons and Solutions

Denial Reason	How to Overturn	Required Documentation
Step therapy required	Submit medical exception	Previous TNF inhibitor trials and failures
Missing TB screening	Complete and submit results	QuantiFERON-TB or TST within 12 months
Not medically necessary	Strengthen clinical rationale	PASI scores, failed treatments, guidelines
Quantity exceeded	Request quantity limit override	Dosing rationale, FDA labeling support
Non-preferred drug	File formulary exception	Contraindications to preferred agents

Cost Savings and Patient Support

Manufacturer Support Programs

• Cosentyx Complete: Patient support and copay assistance
• Novartis Patient Assistance: For uninsured/underinsured patients
• Maximum copay: Often $5-10 per month with commercial insurance

Additional Resources

• Patient Access Network Foundation: Grants for specialty medications
• HealthWell Foundation: Copay assistance programs
• State pharmaceutical assistance: Texas SPAP programs (verify eligibility)

FAQ

How long does Cigna prior authorization take in Texas? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests are processed within 24 hours when delay could jeopardize health.

What if Cosentyx is not on my Cigna formulary? You can request a formulary exception by documenting medical necessity and why formulary alternatives are inappropriate. Include contraindications or previous treatment failures.

Can I get expedited appeals in Texas? Yes, both Cigna internal appeals and Texas external reviews offer expedited pathways when delays could seriously jeopardize your health or interrupt current effective treatment.

Does step therapy apply if I failed biologics in another state? Yes, documented treatment history from other states is valid. Ensure your new Texas provider has complete records of previous therapies and outcomes.

What happens if my appeal is denied? After exhausting Cigna's internal appeals, you can request an external review through the Texas Department of Insurance at no cost. The IRO's decision is binding on Cigna.

How do I prove medical necessity for Cosentyx? Include objective severity measures (PASI scores, inflammatory markers), documented failures of preferred treatments, and clinical rationale supported by FDA labeling or specialty guidelines.

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From our advocates: We've seen that the most successful Cosentyx appeals in Texas include comprehensive TB screening documentation upfront and detailed treatment histories showing specific reasons each prior biologic was discontinued. Taking time to gather complete records before the initial submission often prevents denials altogether.

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For complex cases involving multiple denials or unusual circumstances, platforms like Counterforce Health can help identify the specific denial basis and draft evidence-backed appeals that address payer-specific criteria and procedural requirements.

Sources & Further Reading

• Cigna Cosentyx Prior Authorization Policy
• Cigna Premier Access PA Criteria
• Texas Department of Insurance Appeals Process
• Cosentyx Prescribing Information
• Texas External Review Guide

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Disclaimer: This guide is for informational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for specific coverage questions. For assistance with Texas insurance issues, contact the Texas Department of Insurance at 1-800-252-3439.

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