Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Cosentyx

The insurer denied coverage for Cosentyx

The denial is upheld.

 
The patient is an adult with a diagnosis of psoriasis.  The patient has failed topical therapy with steroids, calcipotriene, and tacrolimus.  The patient has been on Cosentyx with reported good results.  The request is for Cosentyx.  

There are no definitive, comparative, controlled, double blinded, head-to-head studies showing that Cosentyx has a superior efficacy or safety profile for a patient of this type compared to reasonable alternatives such as Humira, Stelara, Tremfya, Taltz or other formulary biologics.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

There is no documentation to suggest that Cosentyx would be more effective than the available formulary alternatives or that the patient has a contraindication to a preferred medication which would specifically necessitate Cosentyx.  Of note, Taltz is a formulary-approved medication which  is also an interleukin (IL)-17A inhibitor, as is  Cosentyx.  

The insurer's required/formulary prescription drug(s) (an adalimumab product [adalimumab-adaz, Humira, or Hyrimoz], Otezla, Skyrizi, Stelara, Taltz and Tremfya) are not contraindicated or likely to cause an adverse reaction or physical or mental harm to the patient.

The insurer's required/formulary prescription drug(s) (an adalimumab product [adalimumab-adaz, Humira, or Hyrimoz], Otezla, Skyrizi, Stelara, Taltz and Tremfya) are not expected to be ineffective, based on the patient's known clinical history, condition and prescription drug regimen.

The patient has not tried the insurer's required/formulary prescription drug(s) (an adalimumab product [adalimumab-adaz, Humira, or Hyrimoz], Otezla, Skyrizi, Stelara, Taltz and Tremfya)  under their current or previous health insurance coverage, or another prescription drug in the same pharmacologic class or with the same mechanism of action, and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.

It is not accurate to say that the insurer's required/formulary prescription drug(s) (an adalimumab product [adalimumab-adaz, Humira, or Hyrimoz], Otezla, Skyrizi, Stelara, Taltz and Tremfya) is not in the patient's best interest because it will likely cause a significant barrier to the patient's adherence to or compliance with the patient's plan of care; will likely worsen a comorbid condition; or will likely decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities.

Based on the submitted documentation and the standard of care, the step therapy requirements were not met in order for this patient to receive Cosentyx. The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities (an adalimumab product [adalimumab-adaz, Humira, or Hyrimoz], Otezla, Skyrizi, Stelara, Taltz and Tremfya) which would make the specific use of Cosentyx necessary.  

The step therapy requirements were not met. 

The insurer's decision to deny coverage for Cosentyx is upheld.