By Counterforce Health Team in Cosentyx (secukinumab) —

How to Get Cosentyx (Secukinumab) Covered by UnitedHealthcare in Florida: Prior Authorization, Appeals, and Formulary Alternatives

Answer Box: Getting Cosentyx Covered by UnitedHealthcare in Florida

UnitedHealthcare requires prior authorization for Cosentyx (secukinumab) and typically mandates step therapy with preferred alternatives like Humira or Enbrel first. To get approved: 1) Have your provider submit PA documentation showing medical necessity and any prior treatment failures, 2) Use OptumRx Specialty Pharmacy for dispensing, and 3) If denied, appeal within 180 days with detailed clinical evidence. Florida residents have external review rights through the state's Department of Financial Services after exhausting internal appeals.

Table of Contents

  1. Coverage Requirements at a Glance
  2. When Formulary Alternatives Make Sense
  3. Typical Alternatives to Cosentyx
  4. Pros and Cons of Alternative Options
  5. Exception Strategy: Requesting Cosentyx
  6. Switching Logistics and Coordination
  7. Re-trying for Cosentyx Later
  8. Appeals Process in Florida
  9. Common Denial Reasons & Solutions
  10. Cost-Saving Options
  11. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Provider must get approval before prescribing UnitedHealthcare Provider Portal UHC PA Requirements
Step Therapy Try preferred alternatives first (usually TNF inhibitors) Commercial formulary documents UHC Commercial PDL
Specialty Pharmacy Must fill through OptumRx Specialty Medicare Advantage plans require this UHC Admin Guide
Medical Necessity Document diagnosis, severity, prior failures Clinical notes and attestation forms UHC PA Notification
Appeals Deadline 180 days from denial for internal appeal Denial letter instructions Florida Insurance Law

When Formulary Alternatives Make Sense

Before pursuing Cosentyx exceptions, it's worth understanding when trying UnitedHealthcare's preferred alternatives might be appropriate. The insurer's step therapy requirements exist because other IL-17 inhibitors and TNF blockers have shown similar efficacy for many patients with psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Clinical considerations for alternatives:

  • No previous biologic failures: If you haven't tried other biologics, alternatives may work equally well
  • Cost concerns: Preferred agents often have lower copays and easier approval processes
  • Administration preferences: Some alternatives offer different dosing schedules or delivery methods
  • Contraindications to Cosentyx: If you have active infections, inflammatory bowel disease, or other conditions that make secukinumab less suitable

When alternatives don't make sense:

  • Previous failure or intolerance to step therapy drugs
  • Specific medical reasons why Cosentyx is uniquely appropriate
  • Urgent need for treatment with documented superiority of secukinumab for your condition

Typical Alternatives to Cosentyx

UnitedHealthcare's formulary typically requires trials of these preferred options before approving Cosentyx:

TNF Inhibitors (First-Line)

  • Humira (adalimumab) - Available as biosimilar; covers psoriasis, PsA, and AS
  • Enbrel (etanercept) - Biosimilar options available; good for psoriasis and PsA
  • Cimzia (certolizumab) - Preferred for certain patients; covers PsA and AS

Other IL-17 Pathway Drugs

  • Taltz (ixekizumab) - Similar mechanism to Cosentyx; may be preferred on some formularies
  • Skyrizi (risankizumab) - IL-23 inhibitor; different pathway but effective for psoriasis

Conventional DMARDs

  • Methotrexate - Often required first for psoriatic arthritis
  • Sulfasalazine - May be required for ankylosing spondylitis

Other Biologics

  • Stelara (ustekinumab) - IL-12/23 inhibitor; biosimilar versions available
  • Otezla (apremilast) - Oral option that may be required before biologics
From Our Advocates: We've seen cases where patients who initially felt frustrated about trying alternatives actually found excellent results with Humira biosimilars or Taltz, often with easier approval processes and lower out-of-pocket costs. The key is working with your provider to document the trial properly so you can move to Cosentyx if needed.

Pros and Cons of Alternative Options

Alternative Pros Cons Access Considerations
Humira/Biosimilars Extensive track record, lower cost, easier approval Injection site reactions, potential for loss of efficacy Usually first-line; multiple biosimilar options
Taltz Similar mechanism to Cosentyx, good efficacy Newer data, similar cost May be preferred over Cosentyx on some formularies
Stelara Different mechanism, good for difficult cases Less frequent dosing but higher per-dose cost Biosimilars becoming available
Methotrexate Oral option, very low cost, well-studied Requires monitoring, GI side effects, contraindicated in pregnancy Usually required first for PsA

Exception Strategy: Requesting Cosentyx

When alternatives aren't appropriate, here's how to build a strong case for Cosentyx approval:

Medical Necessity Documentation

Your provider should include:

  • Specific diagnosis with ICD-10 codes (L40.0 for plaque psoriasis, M07.3 for psoriatic arthritis)
  • Disease severity measures (PASI scores, affected body surface area, joint counts)
  • Prior treatment history with specific drugs, doses, duration, and outcomes
  • Contraindications to preferred alternatives (documented allergies, medical conditions)
  • Clinical rationale for why Cosentyx is specifically needed

Supporting Evidence

Include peer-reviewed studies or guidelines that support Cosentyx use in your specific situation. The FDA prescribing information provides approved indications and dosing.

Required Clinical Criteria

Based on UnitedHealthcare's PA notification, document:

  • Patient meets age requirements (≥6 years for psoriasis, ≥2 years for PsA)
  • No concurrent use of other biologics or targeted immunomodulators
  • Appropriate diagnosis confirmation
  • Step therapy completion or valid exceptions

Switching Logistics and Coordination

Provider Coordination

  • PA submission: Use UnitedHealthcare's provider portal or fax system
  • Clinical documentation: Ensure all required forms and notes are complete
  • Pharmacy coordination: Verify OptumRx Specialty is set up for dispensing

Patient Steps

  1. Insurance verification: Confirm your specific plan's requirements
  2. Prior authorization tracking: Monitor status through member portal
  3. Specialty pharmacy setup: Complete OptumRx enrollment if approved
  4. Financial assistance: Apply for manufacturer copay programs if eligible

Timeline Expectations

  • Initial PA review: 5-10 business days for standard requests
  • Expedited review: 72 hours if urgent medical need is documented
  • Appeal process: 30-60 days for internal appeals

Re-trying for Cosentyx Later

If you start with an alternative, document everything to support a future Cosentyx request:

Documentation During Alternative Trials

  • Response assessment: Regular PASI scores, joint counts, or other objective measures
  • Side effects: Any adverse reactions or tolerability issues
  • Adherence: Confirm you took the medication as prescribed
  • Duration: Adequate trial length (typically 12-16 weeks for biologics)
  • Dose optimization: Whether maximum tolerated doses were tried

Switching Back Criteria

UnitedHealthcare typically allows switching to Cosentyx when alternatives show:

  • Inadequate response: Less than 50% improvement in disease measures
  • Loss of efficacy: Initial response followed by disease worsening
  • Intolerance: Side effects that prevent continued use
  • Contraindications: New medical conditions that make alternatives inappropriate

Counterforce Health specializes in helping patients and providers navigate these complex documentation requirements, turning insurance denials into targeted, evidence-backed appeals that address payers' specific criteria.

Appeals Process in Florida

If your initial PA request is denied, Florida law provides clear appeal rights:

Internal Appeals (Required First Step)

  • Timeline: 180 days from denial to file
  • Process: Submit through UnitedHealthcare member portal or mail
  • Required documents: Denial letter, additional clinical evidence, provider attestation
  • Decision timeframe: 30 days for prospective services, 60 days for retrospective claims

External Review (After Internal Appeals)

  • Eligibility: Available after exhausting internal appeals
  • Timeline: 4 months after final internal denial
  • Process: File with Florida Department of Financial Services
  • Cost: No charge to consumers
  • Contact: Florida Insurance Consumer Helpline

Expedited Appeals

For urgent medical situations:

  • Concurrent filing: Can request internal and external review simultaneously
  • Timeline: 72 hours for external review decision
  • Criteria: Life-threatening condition or risk of serious adverse health consequences

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document prior failures or contraindications Chart notes showing inadequate response or side effects
Insufficient medical necessity Provide detailed clinical rationale PASI scores, joint counts, quality of life measures
Missing prior authorization Resubmit with complete PA forms All required UnitedHealthcare PA documentation
Non-formulary drug Request formulary exception Comparative effectiveness data, clinical superiority evidence
Quantity limits exceeded Justify higher dosing FDA labeling support, clinical guidelines, provider attestation

Cost-Saving Options

Manufacturer Support

  • Novartis copay card: May reduce out-of-pocket costs for eligible patients
  • Patient assistance program: Income-based free drug program
  • Information: Visit Cosentyx.com for current programs

Foundation Grants

  • Patient Advocate Foundation: Provides copay assistance grants
  • HealthWell Foundation: Offers disease-specific assistance programs
  • Good Days: Chronic disease financial assistance

State Programs

Florida residents may qualify for additional assistance through state pharmaceutical programs (verify current availability with Florida Department of Health).

FAQ

How long does UnitedHealthcare PA take in Florida? Standard PA requests typically take 5-10 business days. Expedited requests for urgent medical needs are processed within 72 hours.

What if Cosentyx is non-formulary on my plan? You can request a formulary exception by providing evidence of medical necessity and clinical superiority over covered alternatives.

Can I request an expedited appeal? Yes, if you have an urgent medical need. Document the time-sensitive nature of your condition and risk of serious adverse health consequences without treatment.

Does step therapy apply if I've failed biologics outside Florida? Yes, document all prior biologic failures regardless of where treatment occurred. UnitedHealthcare will consider out-of-state treatment history.

What counts as adequate step therapy trial? Typically 12-16 weeks at maximum tolerated doses, unless contraindicated or intolerable side effects occur earlier.

How do I find my plan's specific formulary? Check your member portal or contact UnitedHealthcare customer service. Medicare Advantage and ACA marketplace plans may have different formularies.

Can my doctor do a peer-to-peer review? Yes, providers can request peer-to-peer reviews with UnitedHealthcare medical directors to discuss complex cases and appeal denials.

What if I'm switching from another insurance plan? UnitedHealthcare may still require step therapy even if you were previously on Cosentyx with another insurer, unless you can document medical necessity for continuation.

This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with insurance appeals in Florida, contact the Florida Department of Financial Services Insurance Consumer Helpline.

Sources & Further Reading

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