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

other FDA labeled or compendia supported indications

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

  • For AS: patient has tried and had an inadequate response to TWO different NSAIDs after ≥4-week total duration, OR one NSAID for ≥4 weeks with intolerance or hypersensitivity to ONE additional NSAID, OR intolerance or hypersensitivity to TWO NSAIDs, OR FDA labeled contraindication to ALL NSAIDs, OR use of another biologic immunomodulator FDA labeled or supported in compendia for AS.
  • For nr-axSpA: patient has tried and had an inadequate response to TWO NSAIDs after ≥4-week total duration, OR one NSAID for ≥4 weeks with intolerance or hypersensitivity to ONE additional NSAID, OR intolerance or hypersensitivity to TWO NSAIDs, OR FDA labeled contraindication to ALL NSAIDs, OR use of another biologic immunomodulator FDA labeled or supported in compendia for nr-axSpA.
  • For PJIA: patient has tried and had an inadequate response to ONE conventional agent (methotrexate, leflunomide) after ≥3-month duration, OR has intolerance or hypersensitivity to ONE conventional agent, OR FDA labeled contraindication to ALL conventional agents, OR use of another biologic immunomodulator FDA labeled or supported in compendia for PJIA.
  • For GCA: patient has tried and had an inadequate response to ONE systemic corticosteroid (e.g., prednisone, methylprednisolone) after ≥7-day duration, OR intolerance or hypersensitivity to ONE systemic corticosteroid, OR FDA labeled contraindication to ALL systemic corticosteroids, OR use of another biologic immunomodulator FDA labeled or supported in compendia for GCA.
  • For other FDA labeled indication: patient age is within FDA labeling or is supported in compendia.
  • If request is for Cosentyx vial, ONE of: plan is BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured municipalities/counties member, OR patient has tried a self-administered Cosentyx agent, OR is currently being treated and stable, OR has tried and had inadequate response to one self-administered Cosentyx agent, OR discontinued due to lack of efficacy/effectiveness/adverse event, OR intolerance/hypersensitivity to one self-administered agent, OR FDA labeled contraindication to all self-administered agents, OR one self-administered agent expected to be ineffective / cause barrier / worsen comorbidity / decrease ability / cause harm, OR one not in the best interest by medical necessity, OR has tried another prescription drug in same class as one self-administered agent and discontinued due to lack of efficacy/effectiveness/adverse event, OR there is support for provider-administered product over self-administered products.
  • Prescribing information TB test requirements must be met.
  • Prescriber is a specialist in relevant diagnosis or has consulted with one.
  • Requested agent not used in combination with another immunomodulator unless labeling allows and clinical support provided.
  • Patient has no FDA labeled contraindications.
  • If member resides in Ohio and plan is Fully Insured or HIM Shop, PA approved when patient has no FDA contraindication AND indication is FDA labeled, or compendia supported, or supported by two peer-reviewed journal articles.

Reauthorization criteria

  • Patient previously approved through plan’s Prior Authorization process (tocilizumab for CRS, Omvoh for CD/UC, ustekinumab for CD/UC, Skyrizi for CD/UC, Tremfya for UC require initial review).
  • Patient has had clinical benefit with the requested agent.
  • Prescriber is specialist or consulted with specialist in diagnosis area.
  • Requested agent not used with another immunomodulator unless labeling allows and combination use is supported.

Approval duration

12 months; exceptions: Tocilizumab for CRS up to 4 doses in 1 month (3 months for some plans); Entyvio (Crohn’s disease or ulcerative colitis) 14 weeks; Omvoh (Crohn’s disease or ulcerative colitis) 12 weeks; Skyrizi (Crohn’s disease or ulcerative colitis) 12 weeks; Ustekinumab (Crohn’s disease or ulcerative colitis induction) 3 months; Tremfya (ulcerative colitis) 12 weeks