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The Policy VaultThe Policy Vault

Cosentyx — Medica

Ankylosing Spondylitis

Preferred products

  • Enbrel
  • Humira
  • Amjevita
  • Rinvoq
  • Taltz
  • Xeljanz tablets
  • Xeljanz XR
  • Cimzia
  • Otezla
  • Skyrizi subcutaneous (pen or syringe)
  • Stelara subcutaneous
  • Tremfya

Initial criteria

  • Patient meets the standard Inflammatory Conditions – Cosentyx Prior Authorization Policy criteria AND indicates approval for initial therapy as directed.
  • For Other Conditions (includes a patient < 18 years of age with Psoriatic Arthritis): Approve if the patient meets the standard Inflammatory Conditions – Cosentyx Prior Authorization Policy criteria.

Reauthorization criteria

  • Patient is currently receiving Cosentyx AND meets the following:
  • i. Patient meets the standard Inflammatory Conditions – Cosentyx Prior Authorization Policy criteria; AND
  • ii. ONE of the following:
  • a) Ankylosing Spondylitis – patient has tried TWO of Enbrel, an adalimumab product (Humira, Amjevita), Rinvoq, Taltz, Xeljanz/XR; OR equivalent trials of Cimzia, infliximab products, or Simponi also count.
  • b) nr-axSpA – patient has tried TWO of Cimzia, Taltz, and Rinvoq; equivalent trials of Enbrel, adalimumab products, infliximab products, or Simponi also count.
  • c) Plaque Psoriasis (≥ 18 years) – patient has tried FOUR medications from at least three groupings: 1) Enbrel or adalimumab product (Humira, Amjevita); 2) Skyrizi SC or Tremfya; 3) Stelara SC; 4) Taltz; 5) Otezla. Trials of Cimzia or infliximab products also count as TNFi.
  • d) Plaque Psoriasis (< 18 years) – patient has tried BOTH of Taltz and Stelara SC.
  • e) Psoriatic Arthritis – patient has tried THREE medications from at least two groupings: 1) Enbrel or adalimumab product (Humira, Amjevita); 2) Skyrizi SC or Tremfya; 3) Stelara SC; 4) Taltz; 5) Rinvoq or Xeljanz/XR; 6) Otezla. Trials of Cimzia, infliximab products, or Simponi also count. Trials of multiple adalimumab or Xeljanz products count as one.
  • f) Patient established on Cosentyx for at least 90 days with 90‑day claims history within past 130 days (or prescriber verification if unavailable) AND meets ≥1 of:
  • (1) Prior sub-therapeutic response/intolerance to Taltz or Siliq; OR
  • (2) Ankylosing Spondylitis or nr-axSpA – prior inadequate efficacy/intolerance with ≥2 biologics; OR
  • (3) Plaque Psoriasis (≥18 years) – prior inadequate efficacy/intolerance with ≥3 meds from ≥2 classes (IL‑12/23 blocker, IL‑23 blocker, TNF inhibitor); OR
  • (4) Psoriatic Arthritis – prior inadequate efficacy/intolerance with ≥3 meds from ≥2 classes (IL‑12/23 blocker, IL‑23 blocker, TNFi, JAK inhibitor, T‑cell costimulation modulator); OR
  • (5) Received Cosentyx ≥90 days concomitantly with a traditional systemic medication for the condition; OR
  • (6) Plaque Psoriasis – received Cosentyx ≥90 days in combination with phototherapy.

Approval duration

1 year