Cosentyx (subcutaneous or intravenous) — Medica
plaque psoriasis
Preferred products
- Enbrel
- adalimumab-adbm
- adalimumab-adaz
- adalimumab-ryvk
- Simlandi
- Otezla
- Rinvoq
- Rinvoq LQ
- Skyrizi subcutaneous (pen or syringe)
- Imuldosa subcutaneous
- Selarsdi subcutaneous
- ustekinumab-ttwe subcutaneous
- Yesintek subcutaneous
- Taltz
- Tremfya subcutaneous
- Xeljanz
- Xeljanz XR
- Cimzia
- Sotyktu
Initial criteria
- Patient meets the standard Inflammatory Conditions – Cosentyx Subcutaneous Prior Authorization Policy criteria
- Patient meets ONE of the following:
- a) Ankylosing spondylitis – tried TWO of Enbrel, an adalimumab product, Rinvoq, Taltz, and Xeljanz/XR [documentation required]
- b) nr-axSpA – tried TWO of Cimzia, Taltz, and Rinvoq [documentation required]
- c) Plaque psoriasis – tried TWO of Enbrel, an adalimumab product, Otezla, Sotyktu, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, and Tremfya subcutaneous [documentation required]
- d) Psoriatic arthritis age ≥ 18 years – tried TWO of Enbrel, an adalimumab product, Otezla, Rinvoq/Rinvoq LQ, Skyrizi subcutaneous, an ustekinumab subcutaneous product, Taltz, Tremfya subcutaneous, or Xeljanz/XR [documentation required]
- e) Psoriatic arthritis age < 18 years – tried ONE of Enbrel, Otezla, Rinvoq/Rinvoq LQ, or an ustekinumab subcutaneous product [documentation required]
- f) Prescriber attests patient with AS, nr-axSpA, or PsA has been established on Cosentyx IV ≥ 90 days
- g) Patient established on Cosentyx SC ≥ 90 days with paid claims verification or prescriber attestation if claims unavailable
Reauthorization criteria
- Patient continues to meet the standard Inflammatory Conditions – Cosentyx Prior Authorization Policy criteria
Approval duration
1 year