By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Humana in New York: Prior Authorization, Appeals, and Step Therapy Guide

Answer Box: Getting Cosentyx Covered by Humana in New York

Cosentyx (secukinumab) requires prior authorization from Humana and typically sits on Tier 5 (Specialty) with step therapy requirements. Your fastest path to approval: Have your doctor submit a PA request with documented failure of preferred biologics, negative TB screening, and severity measures. If denied, you have 65 days to appeal internally, then can request New York's external review through the Department of Financial Services. Start today: Call Humana at the number on your member ID card to confirm your plan's specific requirements and preferred biologics list.

Table of Contents

  1. Humana Plan Types & Coverage Implications
  2. Cosentyx Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Requirements
  4. Specialty Pharmacy Partners & Patient Setup
  5. Cost-Share Basics for Specialty Biologics
  6. Submission Process & Required Documentation
  7. Appeals Process: Internal & New York External Review
  8. Common Denial Reasons & How to Fix Them
  9. FAQ: Cosentyx Coverage Questions
  10. Sources & Further Reading

Humana Plan Types & Coverage Implications

Humana operates primarily as a Medicare Advantage insurer in New York, though they also offer some commercial plans. Your plan type affects how Cosentyx coverage works:

  • Medicare Advantage (Part C): Cosentyx falls under your plan's formulary with prior authorization required
  • Medicare Part D: Prescription drug coverage with federal appeals rights
  • Commercial plans: May have different formularies and state-level appeal rights
Note: Most Humana members in New York have Medicare Advantage plans that combine medical and prescription coverage.

Cosentyx Formulary Status & Tier Placement

Cosentyx is covered on Humana Medicare Advantage formularies as a specialty drug, typically on Tier 5 (Specialty Tier), with prior authorization required. Here's what this means:

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before coverage Humana PA Lists
Tier 5 (Specialty) Higher cost-sharing than generic drugs Your plan's formulary
Step Therapy Must try preferred biologics first Part B Step Therapy List
Quantity Limits Often 30-day supply maximum Plan documents
TB Screening Negative test required before starting PA form requirements

The specific preferred biologics you must try before Cosentyx vary by condition and are updated regularly in Humana's Medicare Part B Step Therapy Preferred Drug List.

Prior Authorization & Step Therapy Requirements

Medical Necessity Criteria

Humana requires comprehensive documentation for Cosentyx approval:

Required Documentation:

  • FDA-approved diagnosis confirmation (moderate-to-severe plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, or hidradenitis suppurativa)
  • Disease severity measures (BSA >10% for psoriasis, objective joint assessments for arthritis)
  • Negative tuberculosis screening (PPD or IGRA test results)
  • Documentation of inadequate response or intolerance to conventional therapy

Step Therapy Process

Before approving Cosentyx, Humana requires documented trials of preferred biologics. Your doctor must show you've tried and failed (or couldn't tolerate) these preferred agents first.

Tip: Ask your doctor to document specific reasons why preferred biologics didn't work—lack of efficacy, side effects, or contraindications. Vague statements like "patient preference" won't meet step therapy exceptions.

Specialty Pharmacy Partners & Patient Setup

Humana partners with Accredo Health and CVS Specialty for Cosentyx dispensing. Here's the typical enrollment process:

Step-by-Step: Specialty Pharmacy Setup

  1. Doctor prescribes Cosentyx and sends to Accredo or CVS Specialty
  2. Pharmacy initiates prior authorization with Humana
  3. Patient enrollment call from pharmacy (answer unfamiliar 800-numbers!)
  4. Insurance verification and benefit confirmation
  5. Clinical consultation about storage, injection technique, side effects
  6. Delivery scheduling to your home address
  7. Ongoing support including refill coordination and nursing help

Cosentyx Connect, Novartis's patient support program, can provide additional injection training and financial assistance coordination.

Cost-Share Basics for Specialty Biologics

As a Tier 5 specialty drug, Cosentyx typically has higher cost-sharing than generic medications. Your exact costs depend on:

  • Deductible status: Whether you've met your annual deductible
  • Coinsurance percentage: Often 25-33% for specialty tiers
  • Out-of-pocket maximum: Annual cap on your total costs
Note: This is educational information only. Contact Humana member services for your specific cost-sharing details.

Financial assistance options:

  • Cosentyx copay cards (eligibility restrictions apply)
  • Patient assistance foundations
  • State pharmaceutical assistance programs

Submission Process & Required Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your doctor's prior authorization request should include:

✓ Problem statement: Specific diagnosis with ICD-10 codes
✓ Prior treatments: Detailed history of failed therapies with dates and outcomes
✓ Clinical rationale: Why Cosentyx is medically necessary now
✓ Guideline support: References to FDA labeling or specialty society guidelines
✓ Dosing plan: Proposed regimen and monitoring approach
✓ TB screening results: Negative PPD/IGRA documentation

Submission methods:

Appeals Process: Internal & New York External Review

If Humana denies your Cosentyx prior authorization, you have strong appeal rights in New York.

Internal Appeals Timeline

For Medicare Part D plans:

  • 65 calendar days from denial date to request redetermination
  • Standard review: Decision within 7 days
  • Expedited review: Decision within 72 hours if urgent

Submit appeals through Humana's member portal or by mail/fax as detailed in your denial letter.

New York External Review Rights

After exhausting Humana's internal appeals, New York residents can request external review through the Department of Financial Services (DFS):

  • Timeline: 4 months after final internal denial to request external review
  • Cost: Maximum $25 filing fee (waived for financial hardship/Medicaid)
  • Expedited process: 72-hour decisions for urgent needs
  • Binding decision: If external reviewer approves, Humana must cover Cosentyx

File external appeals through the DFS online portal or contact Community Health Advocates at 888-614-5400 for free assistance.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Step therapy not completed" Document failed trials of preferred biologics with specific outcomes
"Insufficient severity documentation" Provide objective measures (BSA, joint counts, validated scales)
"Missing TB screening" Submit negative PPD or IGRA test results
"Not medically necessary" Strengthen clinical rationale with guideline references
"Quantity limit exceeded" Justify dosing with FDA labeling or specialty guidelines

From Our Advocates: We've seen many Cosentyx denials overturned when doctors resubmit with detailed documentation of why two preferred biologics specifically failed—for example, "Patient developed injection site reactions requiring treatment discontinuation" rather than just "intolerance." The key is specific clinical details, not general statements.

FAQ: Cosentyx Coverage Questions

How long does Humana prior authorization take in New York?
Standard PA decisions are typically made within 15 business days, though expedited reviews can be processed within 24-72 hours for urgent cases.

What if Cosentyx is non-formulary on my plan?
You can request a formulary exception through the same prior authorization process, though approval rates may be lower than for formulary drugs with restrictions.

Can I request an expedited appeal in New York?
Yes, both Humana internal appeals and New York external reviews offer expedited processes when your health could be seriously jeopardized by delays.

Does step therapy apply if I tried biologics outside New York?
Yes, documented trials from any state typically count toward step therapy requirements, as long as you have medical records showing the attempts and outcomes.

What's the difference between internal and external appeals?
Internal appeals are reviewed by Humana; external appeals are reviewed by independent medical experts assigned by New York state, and their decisions are binding on Humana.

How much does Cosentyx cost with Humana coverage?
Costs vary significantly by plan, but specialty tier drugs often have 25-33% coinsurance after deductible. Contact Humana member services for your specific cost-sharing.

Getting Cosentyx covered by Humana in New York requires navigating prior authorization requirements, but the state's strong external appeal rights provide an important safety net when initial requests are denied. The key is thorough documentation of medical necessity and persistence through the appeals process when needed.

For patients and providers dealing with complex insurance approvals, Counterforce Health offers specialized support in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify denial reasons and draft point-by-point rebuttals aligned to each payer's specific requirements, streamlining the often complex process of securing coverage for specialty medications like Cosentyx.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Insurance coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in New York, contact the state's Consumer Assistance Program or Community Health Advocates.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.