Specialty Quantity Limit Cosentyx 1737-H P2023a - Specialty Pharmacy Clinical Policy Bulletins Aetna Non-Medicare Prescription Drug Plan

Specialty Pharmacy Clinical Policy Bulletins
Aetna Non-Medicare Prescription Drug Plan

Subject: Specialty Quantity Limit Cosentyx 1737-H P2023a

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 pre-filled syringe	1 syringe per 28 days	5 syringes per 28 days	Psoriatic arthritis (PsA)/Ankylosing spondylitis (AS)/Non-radiographic axial spondyloarthritis (NR-axSpA), adults: • 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 Psoriatic arthritis, pediatric (2 years and older): • ≥ 15 kg to < 50 kg: 75 mg at weeks 0, 1, 2, 3, and 4, then 75 mg every 4 weeks • ≥ 50 kg: 150 mg at weeks 0, 1, 2, 3, and 4, then 150 mg every 4 weeks Plaque psoriasis, with or without coexistent psoriatic arthritis, adults: • 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) Plaque psoriasis, pediatric (6 years and older): • < 50 kg: 75 mg at weeks 0, 1, 2, 3, and 4, then 75 mg every 4 weeks • > 50 kg: 150 mg at weeks 0, 1, 2, 3, and 4, then 150 mg every 4 weeks Enthesitis-Related Arthritis (4 years and older): • ≥ 15 kg to < 50 kg: 75 mg at weeks 0, 1, 2, 3, and 4, then 75 mg every 4 weeks • ≥ 50 kg: 150 mg at weeks 0,1, 2, 3 and 4, then 150 mg every 4 weeks
Cosentyx (secukinumab): 150 mg/mL pre-filled pen or syringe	1 pen/syringe per 28 days	5 pens/syringes per 28 days
Cosentyx (secukinumab): 300 mg/2 mL pre-filled pen or syringe	1 pen/syringe per 28 days	5 pens/syringes per 28 days
Cosentyx (secukinumab): 300 mg dose carton containing (2) 150 mg/mL pre-filled pens or (2) 150 mg/mL pre-filled syringes	1 dose carton per 28 days	5 dose cartons per 28 days

*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:

Cosentyx [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; May 2023.

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.

August 13, 2023

Additional Information

Clinical Policy Bulletin Notes

Company Information \| Site Map	Aetna.com Home \| Help \| Contact Us \| Search
Web Privacy Statement \| Legal Statement \| Privacy Notices \| Member Disclosure