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

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: ONE of the following: (A) Tried and had inadequate response to TWO different NSAIDs for at least 4-week total duration; OR (B) Tried one NSAID ≥4 weeks and has intolerance or hypersensitivity to one additional NSAID; OR (C) Intolerance or hypersensitivity to TWO NSAIDs; OR (2) FDA labeled contraindication to ALL NSAIDs; OR (3) Medication history shows use of another biologic immunomodulator labeled or compendia-supported for AS.
• For nr-axSpA: ONE of the following: (A) Tried and had inadequate response to TWO NSAIDs ≥4 weeks total; OR (B) Tried one NSAID ≥4 weeks and intolerance/hypersensitivity to one additional NSAID; OR (C) Intolerance or hypersensitivity to TWO NSAIDs; OR (2) FDA labeled contraindication to ALL NSAIDs; OR (3) Medication history indicates use of another biologic immunomodulator labeled or compendia-supported for nr-axSpA.
• For PJIA: ONE of the following: (A) Tried and had inadequate response to ONE conventional agent (e.g., methotrexate, leflunomide) ≥3 months; OR (B) Intolerance or hypersensitivity to ONE conventional agent; OR (2) FDA labeled contraindication to ALL conventional agents; OR (3) Medication history indicates use of another biologic immunomodulator labeled or compendia-supported for PJIA.
• For GCA: ONE of the following: (A) Tried and had inadequate response to ONE systemic corticosteroid ≥7 days; 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 labeled or compendia-supported for GCA.
• If the patient has an FDA labeled indication, the patient’s age must be within FDA labeling or supported by evidence.
• If the patient has a compendia-supported indication, additional support must be present.
• For Cosentyx vial vs self-administered products: member may qualify if ANY of the following: (A) BCBS IL Fully Insured, HIM, or Non-ERISA ASO/Self-insured Municipalities/Counties member; OR (B) Tried self-administered Cosentyx agent; OR (C) Currently treated and stable on requested agent; OR (D) Tried and inadequate response to one self-administered Cosentyx agent; OR (E) Discontinued self-administered Cosentyx due to adverse event or diminished effect; OR (F) Intolerance or hypersensitivity to one self-administered Cosentyx agent not expected with the requested agent; OR (G) FDA labeled contraindication to ALL self-administered Cosentyx agents; OR (H) Self-administered Cosentyx agent expected to be ineffective or cause barrier or harm; OR (I) Self-administered Cosentyx not in best interest based on medical necessity; OR (J) Tried another prescription drug in same class as self-administered Cosentyx discontinued due to adverse event or diminished effect; OR (K) Support for use of provider-administered product over self-administered products.
• Testing for latent tuberculosis required per prescribing information and initiation of therapy if positive.
• Prescriber must be a specialist or consult with a specialist in the diagnosis area.
• Requested agent not to be used with other immunomodulator unless labeling allows and combination is supported.
• No FDA labeled contraindications to the requested agent.

Reauthorization criteria

• Patient previously approved through plan's prior authorization process.
• Patient has had clinical benefit with the requested agent.
• Prescriber is a specialist or has consulted with a specialist in the patient's diagnosis area.
• Not used with another immunomodulator unless labeling allows and combination is supported.

Approval duration

12 months