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Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan
Subject: Specialty Quantity Limit Cosentyx 1737-H P2022

Drug
COSENTYX  (secukinumab)


Policy:

       I.  PROGRAM DESCRIPTION

           The standard limit is designed to allow a quantity sufficient for
           the most common uses of the medication. If member’s plan
           allows a quantity limit exception review for the requested
           medication, coverage of an additional quantity may be provided
           up to the exception limit with prior authorization.

 
     II.  COVERED QUANTITIES

  Medication

 Standard Limit

   Exception Limit*

   FDA-recommended dosing

 Cosentyx
 (secukinumab):
 75 mg/0.5 mL
 syringe

 1 syringe
 per 28 days

 5 syringes
 per 35 days

 PsA/AS/axSpA:
 •    Loading doses (optional):
      150 mg at weeks 0, 1, 2, 3, 4
 •    Maintenance dose:
      150 mg every 4 weeks
 •    Continued active PsA/AS:
       300 mg every 4 weeks

 

 Plaque psoriasis in adults, with
 or without coexistent psoriatic
 arthritis:
 •    Loading doses:
       300 mg at weeks 0, 1, 2, 3, 4
 •    Maintenance dose:
       300 mg every 4 weeks
       (150 mg every 4 weeks may
       be acceptable)

 

 Pediatric Plaque Psoriasis (6
 years and up):
 •    < 50 kg: Loading doses of 75
       mg at weeks 0, 1, 2, 3, and 4
       and maintenance dose of 75
       mg every 4 weeks
 •    > 50 kg: Loading doses of 150
      mg at weeks 0, 1, 2, 3, and 4
      and maintenance dose of 150
      mg every 4 weeks

 

 Enthesitis-Related Arthritis (4
 years and up):
 •    ≥ 15 kg and < 50 kg: Loading
       doses of 75mg at weeks 0, 1,
       2, 3.and 4 and maintenance
       dose of 75 mg every 4 weeks
 •     ≥ 50 kg: Loading dose of
       150mg at weeks 0,1, 2, 3 and
       4 and maintenance dose of
       150mg every 4 weeks

 Cosentyx
 (secukinumab):
 150 mg/mL
 pen or syringe

 1 pen/syringe
 per 28 days

 5 pens/syringes
 per 35 days

 Cosentyx
 (secukinumab):
 300 mg dose
 carton   containing (2)
 150 mg/mL
 pens or (2) 150
 mg/mL syringes

 1 dose carton
 per 28 days

 5 dose cartons
 per 35 days

Abbreviations: PsA = psoriatic arthritis; AS = ankylosing spondylitis; axSpA = axial spondyloarthritis
*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval


Place of Service:

Outpatient

The above policy is based on the following references:
  1. Cosentyx [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; December 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 26, 2022
Aetna
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