Prescription ClaimsPosted by annoyedparent124

BCBS forcing step therapy on Cosentyx after 3 years of stable use - has anyone successfully appealed for "continuation of care"?

looking for anyone who has been through this specifically. i have psoriatic arthritis, diagnosed 2022, was on methotrexate alone for 14 months which barely touched it, then my rheumatologist put me on Cosentyx (secukinumab) in september 2023 and it has been life changing. went from pain levels 7-8 every day, swollen fingers and feet, to basically asymptomatic. labs are normal. joint counts are normal. i hike, i lift, i live my life.

my employer switched our group plan from Anthem to BCBS of illinois effective june 1 (2026). first refill request through the new plan came back denied yesterday. the denial letter says Cosentyx is non-formulary and i need to "demonstrate medical necessity through step therapy" with their preferred TNF inhibitor (Inflectra, a Remicade biosimilar) for a minimum of 6 weeks before they will approve Cosentyx. they are telling a stable patient to STOP what is working and try a different drug class for 6 weeks to "see if it fails." this is insane to me.

the rheumatologist is on it and writing the appeal but i wanted to know what specifically has worked for others. some questions: 1) is "continuation of care" a real protected pathway under most state laws or am i imagining that? i thought illinois had something about not being forced to switch stable therapies when changing plans. 2) does the manufacturer have a bridge program for situations like this so i dont have a 6 week gap? Novartis has the Now Card but i think that is copay assistance not full fill. 3) if i lose the appeal, what is the timeline for an external review through the state and does my drug get covered during the external review window? 4) anyone successfully gone direct to BCBS medical director by name? someone told me i need to find their pharmacy P&T committee chair and copy them on the appeal.

i have one refill of Cosentyx left in my fridge. that buys me about 8 weeks. trying to map out the worst case before i panic. flare ups for me are not just discomfort, i literally cant make a fist some mornings, and last time i flared i missed two weeks of work. thanks for any guidance.

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BCBS forcing step therapy on Cosentyx after 3 years of stable use - has anyone successfully appealed for "continuation of care"? | ClaimCave