By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by Humana in Virginia: ICD-10 Codes, HCPCS Billing, and Appeals Guide

Answer Box: Getting Cosentyx (Secukinumab) Covered by Humana in Virginia

Cosentyx (secukinumab) requires prior authorization from Humana with step therapy through preferred biologics first. The fastest path: your doctor submits a PA request via Humana's provider portal with proper ICD-10 codes (L40.0 for plaque psoriasis, L40.5x for psoriatic arthritis), documented failure of preferred alternatives, and negative TB screening. If denied, Virginia's State Corporation Commission Bureau of Insurance offers external review within 120 days of your final internal appeal. Start today by calling Humana at the number on your ID card to confirm your plan's specific step therapy requirements and preferred drug list.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for Cosentyx Conditions
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Prior Authorization Request Anatomy
  5. Frequent Billing Pitfalls to Avoid
  6. Verification Steps with Humana
  7. Appeals Process in Virginia
  8. Quick Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit Paths

Understanding how Cosentyx is billed determines your coverage path with Humana. The route depends on whether you're receiving the IV or subcutaneous formulation.

Medical Benefit (Part B) - IV Administration

  • When it applies: Cosentyx IV administered in physician office or outpatient clinic
  • Billing code: HCPCS J3247 ("Injection, secukinumab, intravenous, 1 mg")
  • Coverage: Falls under Humana Medicare Part B with 20% coinsurance after deductible
  • Prior auth required: Yes, with step therapy requirements

Pharmacy Benefit (Part D) - Self-Administered

  • When it applies: Subcutaneous pens/syringes for home use
  • Coverage: Humana Medicare Part D or commercial pharmacy benefit
  • Dispensing: Via specialty pharmacy (Accredo, CVS Specialty)
  • Prior auth required: Yes, separate criteria may apply
Note: Most Cosentyx prescriptions are subcutaneous and fall under pharmacy benefits. Confirm with your doctor which formulation they're prescribing.

ICD-10 Mapping for Cosentyx Conditions

Accurate diagnosis coding is critical for Humana approval. Here are the primary ICD-10 codes for Cosentyx-approved conditions:

Condition Primary ICD-10 Code Documentation Requirements
Plaque Psoriasis L40.0 (Psoriasis vulgaris) Well-demarcated erythematous plaques with scales; BSA >10% or PASI score
Psoriatic Arthritis L40.50-L40.59 (Arthropathic psoriasis) Joint involvement plus psoriasis history; specify subtype if known
Ankylosing Spondylitis M45.- (separate from psoriasis codes) Sacroiliitis on imaging; HLA-B27 if available
Hidradenitis Suppurativa L73.2 (outside L40 category) Recurrent nodules in apocrine gland areas

Key Documentation Words That Support Coding

For plaque psoriasis (L40.0):

  • "Well-demarcated plaques"
  • "Silvery-white scales"
  • "Body surface area >10%"
  • "PASI score ≥10"
  • "Moderate to severe psoriasis"

For psoriatic arthritis (L40.5x):

  • "Joint swelling and tenderness"
  • "Morning stiffness >30 minutes"
  • "Dactylitis" (sausage digits)
  • "Enthesitis"
  • "Nail involvement with joint symptoms"
Tip: Don't code psoriasis (L40.0) and psoriatic arthritis (L40.5x) separately. Use L40.5x as primary when both are present.

Product Coding: HCPCS, J-Codes, and NDCs

For IV Administration (Medical Benefit)

  • HCPCS Code: J3247 (per 1 mg)
  • NDC: 00078-1168-61 (verify current with manufacturer)
  • Units calculation: 300 mg dose = 300 units of J3247
  • Required modifiers: JA (intravenous administration)

For Subcutaneous (Pharmacy Benefit)

  • Dispensing: Via NDC-specific billing through specialty pharmacy
  • No J-code: Billed as prescription drug with quantity limits
  • PA required: Through Humana's Part D process

Units Math Example

If your doctor prescribes Cosentyx 300 mg IV:

  • Bill J3247 x 300 units
  • Include NDC 00078-1168-61
  • Add JA modifier for IV route
  • Attach PA approval number

Clean Prior Authorization Request Anatomy

A successful Humana PA request includes these essential elements:

Required Clinical Information

  1. Patient demographics: Name, DOB, Humana member ID
  2. Prescriber details: NPI, specialty (dermatology/rheumatology preferred)
  3. Diagnosis: Specific ICD-10 code with severity documentation
  4. Prior treatments: Documented trials and outcomes of preferred biologics
  5. Clinical rationale: Why Cosentyx is medically necessary
  6. Dosing plan: Proposed regimen and monitoring

Step Therapy Documentation Checklist

Humana requires documented failure of preferred biologics. Include:

  • Drug name and dates tried
  • Duration of trial (typically 3+ months)
  • Reason for discontinuation: Lack of efficacy, side effects, or contraindication
  • Objective measures: PASI scores, joint counts, imaging results
From our advocates: We've seen PA approvals happen fastest when doctors include specific PASI scores or joint count improvements/lack thereof with each failed medication. Vague statements like "patient preference" typically result in denials that require appeals.

TB Screening Requirements

All biologics require negative tuberculosis screening:

  • PPD or IGRA test results (within 6 months)
  • Chest X-ray (within 3 months)
  • Documentation of no active TB

Frequent Billing Pitfalls to Avoid

Common Coding Errors

  1. Wrong unit calculations: J3247 is per 1 mg, not per vial
  2. Missing NDC: Required for all shared HCPCS codes
  3. Incorrect modifiers: JA for IV, not JW (drug amount discarded)
  4. Incomplete diagnosis: L40.9 (unspecified) instead of specific subtype

PA Documentation Gaps

  • Insufficient step therapy: Must show trials of Humana's preferred agents
  • Missing severity measures: BSA, PASI, or joint assessments required
  • Outdated TB screening: Tests must be current per Humana policy
  • Vague medical necessity: Generic statements vs. specific clinical rationale

Submission Timing Issues

  • Late PA submission: Submit before prescription is dispensed
  • Expired authorizations: Most PAs valid 1 year; track renewal dates
  • Missing deadlines: Appeals must be filed within 65 days of denial

Verification Steps with Humana

Before submitting your PA request, verify these details with Humana:

Call Member Services

Phone: Number on your ID card Verify:

  • Current formulary status of Cosentyx
  • Specific step therapy requirements for your plan
  • Quantity limits and refill restrictions
  • Preferred specialty pharmacy network

Use Provider Portal

Access: Humana provider portal Check:

  • Current PA lists for your plan type
  • Step therapy preferred drug requirements
  • Submission forms and fax numbers

Confirm Specialty Pharmacy

Most Cosentyx prescriptions route through:

  • Accredo Specialty Pharmacy
  • CVS Specialty
  • Verify your plan's preferred network

Appeals Process in Virginia

If Humana denies your Cosentyx PA, Virginia offers strong consumer protections through a structured appeals process.

Internal Appeals with Humana

Timeline: 65 days from denial notice How to file:

  • Phone, online portal, or written request
  • Include additional clinical documentation
  • Request peer-to-peer review if available

Virginia External Review Process

After exhausting Humana's internal appeals, Virginia's State Corporation Commission Bureau of Insurance provides independent review.

Eligibility: 120 days from final internal denial Timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours (if delay could jeopardize health)

How to file:

  1. Contact SCC Bureau of Insurance at 804-371-9741
  2. Request Form 216-A (External Review Request)
  3. Submit with all denial letters and clinical documentation

What happens: Independent medical experts review your case using Virginia law and your plan's own policies. Their decision is binding on Humana.

Note: Virginia's external review is free to consumers and has helped many patients get specialty medications covered when internal appeals failed.

When to Contact Virginia Regulators

State Corporation Commission Bureau of Insurance

  • Phone: 804-371-9741
  • Email: [email protected]
  • Website: scc.virginia.gov (verify current contact info)

File a complaint if:

  • Humana misses appeal deadlines
  • You suspect unfair denial practices
  • The external review process isn't followed properly

Quick Pre-Submission Checklist

Before submitting your Cosentyx PA to Humana, verify:

Clinical Documentation

  • Specific ICD-10 diagnosis code (L40.0, L40.5x, etc.)
  • Current severity measures (BSA >10%, PASI ≥10, joint counts)
  • Negative TB screening (PPD/IGRA + chest X-ray)
  • Documented failure of preferred biologics with specific outcomes

Billing Information

  • Correct HCPCS code (J3247 for IV, NDC for subcutaneous)
  • Accurate unit calculations
  • Required modifiers and NDC numbers
  • Current PA form for your Humana plan type

Submission Details

  • Prescriber NPI and specialty listed
  • Member ID and demographic information complete
  • Clinical rationale references FDA labeling or guidelines
  • All required attachments included

Follow-Up Plan

  • Tracking number or confirmation of submission
  • Calendar reminder for decision deadline
  • Backup appeal strategy if denied
  • Virginia external review forms ready if needed

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Cosentyx. Their platform analyzes denial letters, identifies the specific reasons (whether step therapy, medical necessity, or formulary issues), and creates targeted appeals using your plan's own policies and the latest clinical evidence. For complex cases involving multiple failed appeals or urgent medical situations, their expertise in payer-specific workflows can significantly improve approval chances while saving time for both patients and clinicians.

If you're facing repeated denials or need help navigating Humana's specific requirements in Virginia, Counterforce Health's evidence-backed approach may provide the strategic support needed to get your Cosentyx coverage approved.

Frequently Asked Questions

How long does Humana prior authorization take for Cosentyx in Virginia? Standard PA decisions take up to 72 hours for Part D drugs. Expedited reviews (when delay could harm your health) are decided within 24 hours.

What if Cosentyx isn't on my Humana formulary? You can request a formulary exception by proving all covered alternatives are less effective or cause adverse effects. Your doctor must provide a supporting statement.

Does step therapy apply if I tried biologics with a different insurer? Yes, but you'll need documentation from your previous doctor showing specific drugs tried, duration, and reasons for failure or discontinuation.

Can I get temporary coverage while my appeal is pending? Humana may provide up to 31 days of transitional coverage for non-formulary drugs while processing exceptions, especially if you're switching from another plan.

What counts as medical necessity for Cosentyx approval? Diagnosis of moderate-to-severe plaque psoriasis (BSA >10%), psoriatic arthritis with joint involvement, or other FDA-approved conditions, plus documented failure of preferred alternatives.

How much will Cosentyx cost with Humana coverage? Costs vary by plan type. Medicare Part D typically places specialty biologics on Tier 5 with coinsurance around 25-33%. Check your specific plan's formulary for exact copay amounts.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For binding coverage determinations, contact Humana member services directly.

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