Cosentyx 125 mg/5 mL vial — Blue Cross Blue Shield of Montana

Preferred products

• Cosentyx Sensoready pen 150 mg/mL (1 or 2 pen dose)
• Cosentyx UnoReady pen 300 mg/2 mL
• Cosentyx prefilled syringe 75 mg/0.5 mL
• Cosentyx prefilled syringe 150 mg/mL (1 or 2 syringe dose)
• Cosentyx prefilled syringe 300 mg/2 mL

Initial criteria

• Request is for Cosentyx 125 mg/5 mL vial AND ONE of the following:
• A. Request is for a BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member OR
• B. Patient has tried a self-administered Cosentyx agent OR
• C. Patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
• D. Patient has tried and had an inadequate response to ONE self-administered Cosentyx agent [chart notes required] OR
• E. ONE self-administered Cosentyx agent was discontinued due to lack of efficacy or adverse event [chart notes required] OR
• F. Patient has intolerance or hypersensitivity to ONE self-administered Cosentyx agent not expected to occur with requested agent [chart notes required] OR
• G. Patient has an FDA labeled contraindication to ALL self-administered Cosentyx agents not expected to occur with requested agent [chart notes required] OR
• H. ONE self-administered Cosentyx agent is expected to be ineffective or cause significant barrier, harm, or worsen comorbid condition [chart notes required] OR
• I. ONE self-administered Cosentyx agent is not in the best interest of the patient based on medical necessity [chart notes required] OR
• J. Patient has tried another prescription drug in same pharmacologic class or mechanism as ONE self-administered Cosentyx agent and that drug was discontinued due to lack of efficacy or adverse event [chart notes required] OR
• K. There is support for use of requested provider-administered product over self-administered products
• AND TB testing performed or not required per prescribing info;
• AND prescriber is specialist or has consulted with one;
• AND requested agent not used concurrently with another immunomodulatory agent unless evidence supports such combination;
• AND patient has no FDA labeled contraindication to requested agent

Reauthorization criteria

• Patient previously approved through plan’s PA process (note: certain drugs require initial review per policy)
• Patient has had clinical benefit with the requested agent
• Prescriber is a specialist for the diagnosis or has consulted with one
• Requested agent not used with another immunomodulatory agent unless permitted and supported by clinical evidence

Approval duration

12 months (specific shorter durations or one-time approvals apply by drug and condition per policy)