By Counterforce Health Team in Cosentyx (secukinumab) —

Myths vs. Facts: Getting Cosentyx (Secukinumab) Covered by Aetna (CVS Health) in California

Answer Box: Getting Cosentyx Covered by Aetna (CVS Health) in California

Myth: If your doctor prescribes Cosentyx, Aetna must cover it. Fact: Aetna requires prior authorization, step therapy (trying preferred biologics first), and documented TB screening. Success depends on proper documentation of disease severity and prior treatment failures.

Fastest path to approval:

  1. Complete TB screening (TST or IGRA) and hepatitis B/C tests
  2. Document failure/intolerance of preferred biologics (Humira, Enbrel, etc.)
  3. Submit via Aetna provider portal with all clinical records

First step today: Call your dermatologist or rheumatologist to request documentation of all previous biologic treatments and their outcomes.

Table of Contents

  1. Why Myths About Cosentyx Coverage Persist
  2. Top Myths vs. Facts
  3. What Actually Influences Approval
  4. 5 Preventable Mistakes to Avoid
  5. Quick Action Plan: 3 Steps to Take Today
  6. California-Specific Appeal Rights
  7. Resources and Next Steps

Why Myths About Cosentyx Coverage Persist

Misinformation about specialty drug coverage spreads quickly among patients desperate for relief from psoriasis, psoriatic arthritis, or ankylosing spondylitis. Well-meaning friends share stories about "easy approvals" or "guaranteed denials" that don't reflect the complex reality of insurance policies.

The truth is more nuanced. Counterforce Health helps patients navigate these complexities by turning insurance denials into targeted, evidence-backed appeals. We see the same myths repeatedly—and they often lead to unnecessary delays or abandoned treatments.

Understanding the facts can mean the difference between a 30-day approval and months of appeals, or worse, giving up on a medication that could dramatically improve your quality of life.

Top Myths vs. Facts

Myth 1: "If my doctor prescribes Cosentyx, Aetna has to cover it"

Fact: Aetna requires prior authorization for all Cosentyx prescriptions, regardless of your doctor's recommendation. Coverage depends on meeting specific clinical criteria, not just having a prescription.

Myth 2: "Aetna covers Cosentyx the same way for everyone"

Fact: Coverage varies significantly by your specific plan. Some Aetna plans include Cosentyx on their formulary with step therapy requirements, while others may exclude it entirely. Check your plan's formulary or call member services to understand your specific coverage.

Myth 3: "I can skip trying other biologics first"

Fact: Aetna's step therapy requirements typically mandate trying preferred biologics like adalimumab (Humira) or etanercept (Enbrel) first. Exceptions require documented contraindications, allergies, or previous failures with supporting clinical evidence.

Myth 4: "If Aetna denies Cosentyx, I'm out of options"

Fact: California has robust appeal rights. After internal appeals, you can request an Independent Medical Review (IMR) through the Department of Managed Health Care—though success rates for specialty drugs remain around 10-13%.

Myth 5: "Appeals take forever and rarely work"

Fact: Standard appeals must be decided within 30 days, expedited appeals within 72 hours. While IMR overturn rates for prescription drugs are low (~10%), proper documentation significantly improves your chances.

Myth 6: "TB screening is just a formality"

Fact: Incomplete or missing TB screening is one of the most common denial reasons. You need either a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) within 12 weeks of starting Cosentyx.

Myth 7: "Any doctor can prescribe Cosentyx for insurance approval"

Fact: Most Aetna policies require prescriptions from specialists—dermatologists for psoriasis or rheumatologists for psoriatic arthritis and ankylosing spondylitis. Primary care prescriptions often face automatic denials.

Myth 8: "Generic alternatives work just as well"

Fact: Cosentyx (secukinumab) is a biologic with no generic equivalent. Biosimilars may become available, but currently, step therapy typically involves trying other branded biologics, not generic alternatives.

What Actually Influences Approval

Success with Aetna depends on three key factors:

1. Meeting Clinical Criteria

Your condition must meet documented severity thresholds:

  • Plaque psoriasis: Body surface area >10% or PASI score indicating moderate to severe disease
  • Psoriatic arthritis: Active joint involvement despite DMARD therapy
  • Ankylosing spondylitis: Documented inflammatory back pain with imaging confirmation

2. Proper Documentation Trail

Aetna reviews your complete treatment history. Critical documentation includes:

  • Previous systemic therapies tried, with specific drugs, doses, and durations
  • Reasons for discontinuation (lack of efficacy, side effects, contraindications)
  • Current disease activity measures and functional limitations
  • Complete infectious disease screening results

3. Procedural Compliance

Submit requests through proper channels with all required forms. Missing paperwork triggers automatic denials that could have been avoided.

From our advocates: We've seen cases where patients waited months for Cosentyx approval, only to discover their doctor had submitted incomplete TB screening results. A simple follow-up lab test resolved the issue within days. Always verify that all required tests are complete before submission.

5 Preventable Mistakes to Avoid

1. Submitting Incomplete Safety Screening

The mistake: Missing or outdated TB screening, hepatitis B/C tests, or vaccination records.

The fix: Ensure all screening is current within Aetna's required timeframes. TB screening must be within 12 weeks of starting therapy.

2. Vague Prior Treatment Documentation

The mistake: Saying "tried other medications" without specifics.

The fix: Document exact drug names, doses, treatment duration, and specific outcomes or adverse effects for each previous therapy.

3. Missing Appeal Deadlines

The mistake: Waiting too long to appeal denials.

The fix: California gives you 180 days to file internal appeals with most health plans. Mark your calendar immediately after receiving a denial.

4. Not Requesting Expedited Review When Appropriate

The mistake: Accepting standard 30-day review timelines when your condition is urgent.

The fix: If delays risk serious health consequences, request expedited review. Aetna must respond within 72 hours for urgent requests.

5. Giving Up After First Denial

The mistake: Assuming the first "no" is final.

The fix: Use California's appeal process systematically. Many denials are overturned at internal appeal levels with better documentation.

Quick Action Plan: 3 Steps to Take Today

Step 1: Verify Your Coverage (15 minutes)

Call Aetna member services at the number on your insurance card. Ask specifically:

  • Is Cosentyx covered under my plan?
  • What tier is it on the formulary?
  • What step therapy requirements apply?
  • Is prior authorization required?

Step 2: Schedule Safety Screening (Today)

Contact your prescribing doctor to order:

  • TB screening (TST or IGRA blood test)
  • Hepatitis B surface antigen, core antibody, and surface antibody
  • Hepatitis C antibody
  • Complete blood count and liver function tests

Step 3: Gather Treatment History (This week)

Request records from all providers who've treated your condition, including:

  • Names and doses of all previous systemic treatments
  • Duration of each treatment
  • Reason for discontinuation
  • Current disease severity measurements (PASI scores, joint counts, etc.)

California-Specific Appeal Rights

California offers stronger consumer protections than most states through its dual regulatory system:

Department of Managed Health Care (DMHC)

  • Oversees most HMOs and many PPOs
  • IMR requests can be filed online
  • No cost to patients for independent review
  • Standard IMR decisions within 45 days, expedited within 7 days

California Department of Insurance (CDI)

  • Regulates some PPO and indemnity plans
  • External review process for medical necessity disputes
  • Consumer hotline: 800-927-4357
Note: While IMR overturn rates for prescription drugs remain around 10-13%, cases with strong clinical documentation and clear guideline support have better success rates.

Resources and Next Steps

Official Forms and Contacts

Patient Assistance Programs

  • Novartis patient support: Check eligibility for copay assistance
  • Foundation grants for uninsured or underinsured patients
  • State pharmaceutical assistance programs

When You Need Help

If you're struggling with denials or complex appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies specific policy gaps, and drafts point-by-point rebuttals aligned to your plan's own rules.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary by plan and change frequently. Always verify current requirements with your specific insurer and consult your healthcare provider for medical decisions. For assistance with appeals or coverage disputes, contact the California Department of Managed Health Care or Department of Insurance.

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