By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Humana in Michigan: Prior Authorization, Appeals, and ICD-10 Coding Guide

Quick Answer: Getting Cosentyx Covered by Humana in Michigan

Cosentyx (secukinumab) requires prior authorization from Humana and typically involves step therapy—meaning you must try and fail preferred biologic agents first. In Michigan, if denied, you have 65 days to appeal internally through Humana, then 127 days to file an external review with Michigan DIFS. Key steps: 1) Gather documentation of failed prior treatments, 2) Submit PA with proper ICD-10 codes (L40.0 for psoriasis, L40.5 for psoriatic arthritis), 3) If denied, file internal appeal, then external review through Michigan DIFS.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Cosentyx Approval
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Prior Authorization Request
  5. Frequent Coding Pitfalls
  6. Verification with Humana Resources
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Michigan
  9. Cost-Saving Options
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding whether Cosentyx falls under your medical benefit (Part B) or pharmacy benefit (Part D) determines the coding approach and approval pathway.

Medical Benefit (Provider-Administered)

Cosentyx IV is billed under the medical benefit using:

  • HCPCS Code: J3247 ("Injection, secukinumab, intravenous, 1 mg")
  • NDC: 00078-1168-61 (most common IV formulation)
  • Modifier: JA (for IV administration)

Pharmacy Benefit (Self-Administered)

Cosentyx subcutaneous typically falls under Part D pharmacy benefit:

  • Uses different NDCs based on formulation
  • Requires specialty pharmacy (often CenterWell Specialty for Humana)
  • Subject to Part D cost-sharing tiers
Note: Humana classifies Cosentyx as a Tier 5 specialty drug with higher cost-sharing and stringent documentation requirements.

ICD-10 Mapping for Cosentyx Approval

Proper diagnosis coding is crucial for Humana approval. Use these specific ICD-10 codes based on your condition:

Condition ICD-10 Code Documentation Requirements
Plaque Psoriasis L40.0, L40.9 PASI ≥10 or BSA ≥10%, candidate for systemic therapy
Psoriatic Arthritis L40.5 Joint involvement, failed DMARDs
Ankylosing Spondylitis M45 Imaging confirmation, functional impairment
Hidradenitis Suppurativa L73.2 Moderate-to-severe, Hurley Stage II/III

Supporting Documentation Words

When describing your condition, include these clinical terms that support coding:

  • Severity: "moderate-to-severe," "refractory," "extensive"
  • Impact: "quality of life impairment," "functional limitation," "work disability"
  • Location: "hands, feet, face, or genitals" (for psoriasis)
  • Prior treatments: "inadequate response," "intolerance," "contraindication"

Product Coding: HCPCS, J-Codes, and NDCs

HCPCS J3247 Billing Requirements

For provider-administered Cosentyx IV:

  • Units: Bill per 1 mg (e.g., 300 mg dose = 300 units)
  • Required fields: NDC, ICD-10 diagnosis, JA modifier
  • Prior authorization number: Must be included on claim

NDC Considerations

Common Cosentyx NDCs for different formulations:

  • IV: 00078-1168-61
  • Subcutaneous: Various NDCs based on strength and packaging
Tip: Always verify the exact NDC with your pharmacy or provider before billing, as formulations may change.

Clean Prior Authorization Request

A successful Humana PA request includes these essential elements:

Required Clinical Documentation

  1. Confirmed diagnosis with appropriate ICD-10 code
  2. Disease severity metrics:
    • PASI score ≥10 (psoriasis)
    • BSA ≥10% (psoriasis)
    • Joint count and imaging (psoriatic arthritis)
  3. Negative TB screening results
  4. Complete treatment history showing failed preferred agents
  5. Clinical rationale for Cosentyx necessity

Step Therapy Documentation

Humana requires documentation of failed trials with preferred agents, which typically include:

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Ustekinumab (Stelara)
  • Apremilast (Otezla)
Important: Verify current preferred agent list on Humana's formulary, as this updates regularly.

Frequent Coding Pitfalls

Common Mistakes to Avoid

  1. Mismatched ICD-10 codes: Using L40.9 (unspecified psoriasis) instead of L40.0 (plaque psoriasis)
  2. Missing modifiers: Forgetting JA modifier for IV administration
  3. Incorrect units: Billing wrong mg conversion for J3247
  4. Incomplete documentation: Vague prior treatment history
  5. Wrong benefit: Submitting IV claims to pharmacy benefit instead of medical

Unit Conversion Errors

  • J3247 is billed per 1 mg
  • Standard Cosentyx IV dose is 300 mg
  • Therefore: Bill 300 units of J3247, not 1 unit

Verification with Humana Resources

Before submitting your PA or claim:

  1. Check formulary status: Verify Cosentyx placement on your specific Humana plan
  2. Confirm PA requirements: Review Humana's prior authorization list
  3. Validate codes: Cross-reference ICD-10, HCPCS, and NDC codes
  4. Review step therapy: Confirm current preferred agents for your diagnosis

Humana Resources

  • Provider portal: Submit PA requests and check status
  • Pharmacy support: Call for specialty drug questions
  • Member services: Verify benefits and coverage details

Pre-Submission Audit Checklist

Before submitting your Cosentyx request, verify:

  • Correct ICD-10 code for primary diagnosis
  • Appropriate HCPCS/J-code for administration route
  • Accurate NDC for specific product
  • Required modifiers included
  • Prior authorization form completed
  • Clinical documentation attached
  • TB screening results included
  • Step therapy documentation provided
  • Provider specialty noted (dermatology/rheumatology)
  • Patient age verification for pediatric indications

Appeals Process in Michigan

If Humana denies your Cosentyx request, Michigan offers robust appeal rights:

Internal Appeal (Humana)

  • Deadline: 65 days from denial notice
  • Methods: Online, mail, fax, or phone
  • Timeline: 7 days for Part D drugs, 30 days for medical services
  • Expedited option: Available if delay could harm health

External Review (Michigan DIFS)

After internal appeal denial:

  • Deadline: 127 days from final adverse determination
  • Process: File with Michigan DIFS
  • Timeline: 60 days standard, 72 hours expedited
  • Outcome: Binding decision by Independent Review Organization
From our advocates: We've seen Michigan patients successfully overturn Humana denials by submitting comprehensive clinical documentation showing specific adverse reactions to preferred agents, not just "lack of efficacy." The key is detailed provider letters explaining why alternatives won't work for this patient's specific clinical situation.

Required Appeal Documentation

  • Original denial letter
  • Medical records supporting necessity
  • Provider statement of urgency (for expedited review)
  • Failed treatment documentation

For urgent appeals requiring expedited review, your physician must clearly state that delays would jeopardize your health.

Cost-Saving Options

Manufacturer Support

  • Novartis Patient Assistance: Income-based free drug program
  • Copay cards: Up to $16,000 annual savings for eligible patients
  • Eligibility: Generally available for commercial insurance (restrictions for government plans)

Foundation Grants

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days Foundation

Visit manufacturer websites or call patient support programs directly for current eligibility criteria and application processes.

Streamlining Your Approval Process

Getting complex specialty medications like Cosentyx approved requires navigating intricate prior authorization requirements, step therapy protocols, and appeals processes. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create compelling rebuttals aligned with each payer's specific requirements, potentially saving weeks of back-and-forth with insurers.

FAQ

Q: How long does Humana prior authorization take for Cosentyx in Michigan? A: Standard PA decisions are made within 72 hours for formulary exceptions, 7 days for Part D drugs, and up to 30 days for medical benefit requests.

Q: What if Cosentyx is non-formulary on my Humana plan? A: You can request a formulary exception with your prescriber's supporting statement. Humana must respond within 72 hours of receiving complete documentation.

Q: Can I request an expedited appeal if denied? A: Yes, if waiting for a decision could seriously jeopardize your health. Your physician must provide a supporting statement for expedited processing.

Q: Does step therapy apply if I failed treatments outside Michigan? A: Yes, documented treatment failures from any location count toward step therapy requirements, provided you have proper clinical documentation.

Q: What's the difference between internal and external appeals in Michigan? A: Internal appeals go through Humana directly (65-day deadline). External appeals go through Michigan DIFS after internal denial (127-day deadline) and result in binding decisions.

Q: How much will Cosentyx cost with Humana coverage? A: As a Tier 5 specialty drug, expect higher cost-sharing. Exact amounts depend on your specific plan and whether you've met deductibles or out-of-pocket maximums.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and should not replace professional medical or insurance advice. Coverage policies and requirements may change. Always verify current information with Humana and consult your healthcare provider for medical decisions. For additional help with Michigan insurance appeals, contact DIFS at 877-999-6442.

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