Secukinumab (Cosentyx) IV (Medicaid Expansion)

Policy ID: ME-I-9901-001-04

Section: Injections

Effective Date: March 01, 2024

Revised Date: October 20, 2024

Revision Effective Date: December 01, 2024

Last Reviewed: November 19, 2024

Applies To: Medicaid Expansion Only

Description

Secukinumab (Cosentyx®) is a human IgG1 monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine, inhibiting its interaction with the IL-17A receptor.

Secukinumab (Cosentyx) IV may be covered under the medical benefit; please refer to the pharmacy benefit for coverage of secukinumab (Cosentyx) self-administered subcutaneous injection.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

The use of secukinumab (Cosentyx) IV may be considered medically necessary when the following criteria are met:

The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route); and
If the individual has a diagnosis of Ankylosing Spondylitis, the individual must have failed a 30-day trial of Xeljanz and Rinvoq ER, and a 90-day trial of a TNF inhibitor, and a 90-day trial of Taltz, as evidenced by paid claims or pharmacy printouts
If the individual has a diagnosis of Psoriatic Arthritis, the individual must have failed a 90-day trial of a TNF inhibitor and a 90-day trial of Taltz as evidenced by paid claims or pharmacy printouts
Clinical justification must be provided why a self-administered agent cannot be used (subject to clinical review).

Reauthorization Criteria

The individual has previously been approved for secukinumab (Cosentyx) IV through Blue Cross Blue Shield of North Dakota's precertification process; and
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy.

The use of secukinumab (Cosentyx) IV for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J3247

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

L40.50

L40.51

L40.52

L40.53

L40.59

M45.0

M45.1

M45.2

M45.3

M45.4

M45.5

M45.6

M45.7

M45.8

M45.9

M45. A0

M45. A1

M45. A2

M45.A3

M45.A4

M45.A5

M45.A6

M45.A7

M45.A8

M45.AB

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-16-2024 Effective March 01, 2024

Adopted medical policy based on DHHS PDL Version 2024.1

Internal Medical Policy Committee 3-19-2024 Effective April 01, 2024

Added new code, C9166, to the policy

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added new code, J3247, to the policy
Removed code, C9166, from the policy

Internal Medical Policy Committee 11-19-2024 Effective December 01, 2024

Updated criteria to add 'clinical justification must be provided why a self-administered agent cannot be used' based on the DHHS PDL Version 2024.6

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: ME-I-9901-001-03

Section: Injections

Effective Date: March 01, 2024

Revised Date: June 12, 2024

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: November 30, 2024

Applies To: Medicaid Expansion Only

Description

Secukinumab (Cosentyx®) is a human IgG1 monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine, inhibiting its interaction with the IL-17A receptor.

Secukinumab (Cosentyx) IV may be covered under the medical benefit; please refer to the pharmacy benefit for coverage of secukinumab (Cosentyx) self-administered subcutaneous injection.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

The use of secukinumab (Cosentyx) IV may be considered medically necessary when the following criteria are met:

The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route); and
If the individual has a diagnosis of Ankylosing Spondylitis or Psoriatic Arthritis, the individual must have failed a 90-day trial of a TNF inhibitor as evidenced by paid claims or pharmacy printouts; and
If the individual has a diagnosis of Ankylosing Spondylitis, the individual must have also failed a 90-day trial of ixekizumab (Taltz) as evidenced by paid claims or pharmacy printouts.

Reauthorization Criteria

The individual has previously been approved for secukinumab (Cosentyx) IV through Blue Cross Blue Shield of North Dakota's precertification process; and
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy.

Procedure Code

J3247

Diagnosis Codes

L40.50

L40.51

L40.52

L40.53

L40.59

M45.0

M45.1

M45.2

M45.3

M45.4

M45.5

M45.6

M45.7

M45.8

M45.9

M45. A0

M45. A1

M45. A2

M45.A3

M45.A4

M45.A5

M45.A6

M45.A7

M45.A8

M45.AB

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-16-2024 Effective March 01, 2024

Adopted medical policy based on DHHS PDL Version 2024.1

Internal Medical Policy Committee 3-19-2024 Effective April 01, 2024

Added new code, C9166, to the policy

Internal Medical Policy Committee 5-14-2024 Effective July 01, 2024

Added new code, J3247, to the policy
Removed code, C9166, from the policy

Medical Policies Quick Search

Secukinumab (Cosentyx) IV (Medicaid Expansion)

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer