Secukinumab (Cosentyx) — CPB 0905 | AETNA Coverage Update

Aetna modified CPB 0905 for secukinumab (Cosentyx), effective March 5, 2026. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated its Cosentyx coverage policy under CPB 0905 Aetna system, tightening medical necessity criteria across six indications. The update adds age-specific thresholds, step therapy requirements, and prescriber specialty restrictions that directly affect claim approval for HCPCS J3247 (IV secukinumab) and administration codes 96365–96368. If your practice bills Cosentyx for plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, hidradenitis suppurativa, enthesitis-related arthritis, or non-radiographic axial spondyloarthritis, this change affects your prior authorization workflow and your reimbursement rate.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Secukinumab (Cosentyx) — CPB 0905
Policy Code	CPB 0905
Change Type	Modified
Effective Date	March 5, 2026
Impact Level	High
Specialties Affected	Dermatology, Rheumatology
Key Action	Verify prescriber specialty, step therapy history, and age criteria before submitting claims for J3247 or administering IV Cosentyx on or after March 5, 2026

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Aetna Secukinumab Coverage Criteria and Medical Necessity Requirements 2026

The updated Aetna secukinumab coverage policy builds step therapy and prescriber-specialty gatekeeping into every indication. This is the architecture that drives claim denials. Know it before you bill.

Prescriber Specialty Requirements

Aetna will not approve Cosentyx unless the prescribing physician matches the indication. The rules are strict:

#	Covered Indication Copy
1	Plaque psoriasis: Must be prescribed by or in consultation with a dermatologist
2	Psoriatic arthritis and hidradenitis suppurativa: Rheumatologist or dermatologist
3	Ankylosing spondylitis, non-radiographic axial spondyloarthritis, and enthesitis-related arthritis: Rheumatologist only

If a primary care physician writes the Cosentyx prescription without a qualifying specialist consultation on record, expect a denial. Document the consultation clearly in the medical record before submitting.

Plaque Psoriasis (PsO) Medical Necessity Criteria

For members age 6 and older, Aetna considers secukinumab medically necessary when the member:

The 3% BSA threshold is the narrow path. It requires documented step therapy failure. If your records show only that the patient "prefers" to skip methotrexate, that's not a clinical reason under this policy. Make sure the chart supports it.

Psoriatic Arthritis (PsA) Medical Necessity Criteria

For members age 2 and older, Aetna covers secukinumab when the member:

#	Covered Indication Copy
1	Has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Otezla) for active psoriatic arthritis; or
2	Has mild to moderate disease with documented inadequate response to or intolerance of methotrexate, leflunomide, or another conventional synthetic disease-modifying drug (e.g., sulfasalazine) — or has enthesitis or predominantly axial disease; or
3	Has severe disease

"Severe disease" is the only pathway that bypasses conventional DMARD step therapy. Make sure your physician's notes characterize disease severity explicitly. "Moderate" without DMARD failure documentation won't get through.

Ankylosing Spondylitis and Non-Radiographic Axial Spondyloarthritis (AS/nr-axSpA) Medical Necessity Criteria

For adult members, Aetna covers secukinumab when the member:

#	Covered Indication Copy
1	Has previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) for active AS or active nr-axSpA; or
2	Meets active disease criteria for either condition with appropriate prior therapy documentation

Chest X-ray codes 71045–71048 and TB screening codes 86480, 86481, and 86580 appear in the policy as related codes — reflecting the baseline safety testing required before initiating a biologic. Get those on file before prior authorization submission.

Prior Authorization Requirements

Precertification of IV secukinumab (J3247) is mandatory for all Aetna participating providers and members in applicable plan designs. Call (866) 752-7021 or fax (888) 267-3277. For subcutaneous administration billed under CPT 96372, check the specific plan design — PA requirements vary.

Aetna's Site of Care Utilization Management Policy also applies for commercial plans with IV Cosentyx. This is a separate step from the clinical PA. A claim that clears clinical criteria can still deny if the site of care doesn't match the policy. Confirm site of care approval before scheduling the infusion.

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Aetna Secukinumab Exclusions and Non-Covered Indications

The Aetna Cosentyx coverage policy does not extend to off-label uses not addressed in CPB 0905. The ICD-10 codes in this policy — including tuberculosis (A15.0–A19.9), liver cell carcinoma (C22.0), and Alzheimer's disease (G30.0–G30.9) — appear as exclusion-context codes. These reflect contraindications and safety monitoring, not covered indications.

Dry eye syndrome (H04.121–H04.129), secondary noninfectious iridocyclitis (H20.41–H20.49), and Parkinson's disease (G20.A1–G20.C) are also listed — again as safety and monitoring context codes, not treatment indications. Billing Cosentyx against these diagnosis codes will result in claim denial.

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Coverage Indications at a Glance

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Aetna Secukinumab Billing Guidelines and Action Items 2026

Secukinumab billing under CPB 0905 has three layers of failure risk: wrong prescriber specialty, missing step therapy documentation, and site of care mismatch. All three are preventable. Here's how.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Secukinumab Under CPB 0905

HCPCS Codes Covered When Selection Criteria Are Met

Code	Type	Description Copy
J3247	HCPCS	Injection, secukinumab, intravenous, 1 mg

CPT and HCPCS Codes Related to CPB 0905 (Administration, Safety Testing, and Context)

Key ICD-10-CM Diagnosis Codes Referenced in CPB 0905

Note: The full ICD-10 list in CPB 0905 contains 98 codes. The codes above are representative. Most codes in this policy appear as safety monitoring context (e.g., TB screening, contraindication flags) — not as covered treatment indications for Cosentyx. Billing J3247 against TB, Alzheimer's, or Parkinson's diagnosis codes will result in claim denial.

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