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Secukinumab (Cosentyx®)
BCBS Tennessee·TN · Dermatology, Rheumatology, Pediatrics·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
This is a new medical policy for Secukinumab (Cosentyx®) effective 9/30/26 that establishes coverage criteria, prior authorization requirements, and documentation standards for six FDA-approved indications: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, enthesitis-related arthritis, and hidradenitis suppurativa. The policy requires step therapy and mandates prescriber specialty requirements (dermatologist, rheumatologist, or both depending on indication). All other uses are considered experimental/investigational.
Action Required
By September 30, 2026: (1) Billing team must implement prior authorization requirement in billing system for all Secukinumab (Cosentyx®) claims. (2) Update authorization templates to capture required documentation: for plaque psoriasis—BSA affected, previous medications tried/response; for other indications—previous medications and clinical response. (3) Implement prescriber specialty validation rules: require dermatologist for plaque psoriasis; rheumatologist or dermatologist for psoriatic arthritis and hidradenitis suppurativa; rheumatologist only for ankylosing spondylitis, non-radiographic axial spondyloarthritis, and enthesitis-related arthritis. (4) Configure system to reference BCBS Step Therapy Guide at https://www.bcbst.com/docs/providers/Comm_BC_PAD_Step_Therapy_Guide.pdf for step therapy requirements. (5) Update provider encounter forms and prior auth request tools to reflect all six covered indications and age requirements (6+ years for psoriasis, 2+ for PsA, 12+ for AS/nr-axSpA, 4+ for ERA, 12+ for HS). (6) Train billing, prior auth, and clinical staff on coverage criteria thresholds (e.g., prior biologic/targeted synthetic use, BSA thresholds, NSAID failure requirements). Claims submitted without meeting coverage criteria or proper documentation will be denied. Before implementation date: Notify all contracted dermatologists and rheumatologists of new policy requirements.