Cosentyx vial — Blue Cross Blue Shield of New Mexico

Preferred products

• Cosentyx Sensoready pen 150 mg/mL
• Cosentyx UnoReady pen 300 mg/2 mL
• Cosentyx prefilled syringe 75 mg/0.5 mL
• Cosentyx prefilled syringe 150 mg/mL
• Cosentyx prefilled syringe 300 mg/2 mL

Initial criteria

• For AS: ONE of the following must be met: (A) Tried and had inadequate response to TWO different NSAIDs used in the treatment of AS after at least a 4-week total duration of therapy OR (B) Tried and had inadequate response to ONE NSAID after at least a 4-week duration and intolerance or hypersensitivity to ONE additional NSAID OR (C) Intolerance or hypersensitivity to TWO different NSAIDs OR (2) FDA labeled contraindication to ALL NSAIDs used in the treatment of AS OR (3) Medication history indicates use of another biologic immunomodulator agent that is FDA labeled or supported in compendia for the treatment of AS.
• For nr-axSpA: ONE of the following must be met: (A) Tried and had inadequate response to TWO different NSAIDs used in the treatment of nr-axSpA after at least a 4-week total duration OR (B) Tried and had inadequate response to ONE NSAID after at least a 4-week duration and intolerance or hypersensitivity to ONE additional NSAID OR (C) Intolerance or hypersensitivity to TWO different NSAIDs OR (2) FDA labeled contraindication to ALL NSAIDs OR (3) Medication history indicates use of another biologic immunomodulator agent labeled or supported for nr-axSpA.
• For PJIA: ONE of the following must be met: (A) Tried and had inadequate response to ONE conventional agent (e.g., methotrexate, leflunomide) used in treatment of PJIA after at least a 3‑month duration OR (B) Intolerance or hypersensitivity to ONE conventional agent OR (2) FDA labeled contraindication to ALL conventional agents used in PJIA OR (3) Medication history indicates use of another biologic immunomodulator agent labeled or supported for PJIA.
• For GCA: ONE of the following must be met: (A) Tried and had inadequate response to ONE systemic corticosteroid (e.g., prednisone, methylprednisolone) after at least a 7‑day duration OR (B) Intolerance or hypersensitivity to ONE systemic corticosteroid OR (2) FDA labeled contraindication to ALL systemic corticosteroids OR (3) Medication history indicates use of another biologic immunomodulator agent labeled or supported for GCA.
• If requesting Cosentyx vial, ONE of the following must be met: (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 and is stable on the requested agent [chart notes required] OR (D) Tried and had 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, diminished effect, or adverse event [chart notes required] OR (F) Intolerance or hypersensitivity to ONE self‑administered Cosentyx agent (not expected with requested agent) [chart notes required] OR (G) FDA labeled contraindication to ALL self‑administered Cosentyx agents (not expected with requested agent) [chart notes required] OR (H) ONE self‑administered Cosentyx agent is expected to be ineffective, cause significant barrier, worsen comorbidity, or cause harm [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 of action as ONE self‑administered Cosentyx agent and discontinued due to lack of efficacy or adverse event [chart notes required] OR (K) Support for the use of provider‑administered product over self‑administered products.
• Testing requirement: If prescribing information requires testing for latent tuberculosis, patient has been tested for latent TB and, if positive, has begun therapy for latent TB.
• Prescriber requirement: Prescriber is a specialist (or has consulted with one) in the area of the patient’s diagnosis.
• Patient will not be using in combination with another immunomodulatory agent OR, if combination, (1) prescribing information does not limit such use and (2) there is support for combination therapy (e.g., clinical trials, guidelines).
• Patient does not have any FDA labeled contraindications to requested agent.
• For members residing in Ohio with Fully Insured or HIM Shop plans: (A) No FDA labeled contraindications AND ONE of the following: (1) Another FDA labeled indication for requested agent and route OR (2) Another indication supported in compendia OR (3) Submission of two peer‑reviewed journal articles supporting proposed use.

Reauthorization criteria

• Patient has been previously approved for requested agent through plan’s prior authorization process (except specific agents requiring initial review such as tocilizumab for CRS, Omvoh for CD or UC, ustekinumab for CD or UC, Skyrizi for CD or UC, Tremfya for UC).
• Patient has had clinical benefit with requested agent.
• Prescriber is a specialist (or has consulted with one) in area of patient’s diagnosis.
• Patient will not be using in combination with another immunomodulatory agent OR, if combination, (1) prescribing information does not limit such use and (2) support for combination therapy provided.

Approval duration

12 months (exceptions: Tocilizumab for CRS 3 months; Entyvio 14 weeks; Omvoh 12 weeks; Skyrizi 12 weeks; Ustekinumab 3 months; Tremfya 12 weeks)