Changes in coverage or loss of insurance? We can help. Here’s what to do to avoid a disruption in your treatment.
If your insurance plan has changed their coverage of COSENTYX®, it may be due to a change to their prescription drug formulary list. Most insurance plans have a list of preferred and covered medications called a formulary. This list may be re-evaluated every year based on a number of factors, including cost, safety, and effectiveness of the medication. In some instances, the insurance plan might remove COSENTYX from their formulary and exclude it from coverage, which may force a non-medical switch to another medication. A change to your medication for a non-medical reason, especially during the COVID-19 pandemic, may be challenging. If it’s important to you to stay on COSENTYX, a medication you and your doctor decided is the best choice for you, here are steps you can take.
If your insurance coverage has changed:
Call your insurance company and tell them you want to stay on COSENTYX. Ask for information about filing a medical exception and how soon this can be submitted so your COSENTYX coverage doesn’t end. A medical exception can be based on:
- Any prior medications you have taken for your condition
- How long you have been on COSENTYX
- Satisfaction with your results
- Your concern about unnecessary doctor visits during the COVID-19 pandemic
Tell your doctor that you want to stay on COSENTYX and ask your doctor to submit a medical exception to your insurance plan. You can help your doctor by providing the date your insurance plan will be ready to accept your medical exception submission.
To help ensure that you don’t miss a dose of COSENTYX due to this change, your doctor may be able to write a prescription for a 90-day supply of COSENTYX. If this is not possible, your doctor may be able to help you with other options to stay on COSENTYX.
If you’ve lost your insurance:
If you’ve lost your insurance, visit Novartis Patient Assistance NOW to get assistance with finding programs that may help you with your Novartis prescription medications. Learn more at www.PAP.Novartis.com or by calling 1-800-277-2254.
"My doctor said that my insurance was tough, but that COSENTYX® Connect would help me understand my options, and they did. COSENTYX works for me. Four years and counting."
Frequently Asked Questions About Insurance Changes
Get answers to frequently asked questions about insurance changes below or call COSENTYX® Connect at 1-844-267-3689.
Is there a brochure I can download with information on insurance coverage changes?
Yes. Download the PDF here for quick reference or print it out to have handy. Read through it and reference it when calling your insurance company.
What do I do if my insurance plan is not covering COSENTYX because of a non-medical switch?
Insurance plans have a list of preferred and covered medications called a formulary. This list may be re-evaluated every year based on a number of factors, including cost, safety, and effectiveness of the medication. If an insurance plan removes a medication from their formulary and excludes it from coverage, it may force a non-medical switch to another medication.
Insurance companies can switch a patient off of their prescribed medication for reasons other than the effectiveness or safety of the medication, such as 1) a change in the patient's insurance plan, 2) removal of the medication from the formulary list, meaning it is no longer covered, or 3) cost.
If you wish to remain on COSENTYX, you can reach out to your prescription insurance provider and your doctor to request a medical exception and for assistance with next steps.
1. Call your insurance company and tell them you want to stay on COSENTYX. Ask for information about filing a medical exception and how soon this can be submitted so your COSENTYX coverage doesn’t end. A medical exception can be based on:
- Any prior medications you have taken for your condition
- How long you have been on COSENTYX
- Satisfaction with your results
- Your concern about unnecessary doctor visits during the COVID-19 pandemic
2. Tell your doctor that you want to stay on COSENTYX and ask your doctor to submit a medical exception to your insurance plan. You can help your doctor by providing the date your insurance plan will be ready to accept your medical exception submission.
What is a formulary?
A formulary is a regularly updated list of prescription medications approved for reimbursement by an insurance company. This usually happens annually. Medications on this list are often referred to as a “preferred medication.”
My insurance plan says that COSENTYX will no longer be covered. What does this mean?
When a medication is not covered, or “not on formulary,” it means that the product will not be covered by the insurance plan and you may not have access to it for 2021. The insurance company may require you to pay the full cost of COSENTYX if you and your doctor decide that it’s the best treatment option for you. This could happen unless a medical exception/letter of medical necessity is approved by your insurance company. A letter of medical necessity is a patient-specific letter that will help to explain the doctor’s rationale and clinical decision-making in choosing a medication. If you wish to remain on COSENTYX, you can reach out to your insurance plan and your doctor to request a medical exception and for assistance with next steps.
How can I stay on COSENTYX?
In order to stay on COSENTYX, talk to your doctor about filing a medical exception with your insurance plan. You may also want to speak with your employer to see if they can offer help with the medical exception process.
1. Call your insurance company and tell them you want to stay on COSENTYX. Ask for information about filing a medical exception and how soon this can be submitted so your COSENTYX coverage doesn’t end. A medical exception can be based on:
- Any prior medications you have taken for your condition
- How long you have been on COSENTYX
- Satisfaction with your results
- Your concern about unnecessary doctor visits during the COVID-19 pandemic
2. Tell your doctor that you want to stay on COSENTYX and ask your doctor to submit a medical exception to your insurance plan. You can help your doctor by providing the date your insurance plan will be ready to accept your medical exception submission.
To help ensure that you don’t miss a dose of COSENTYX due to this change, your doctor may be able to write a prescription for a 90-day supply of COSENTYX. If this is not possible, your doctor may be able to help you with other options to stay on COSENTYX.
Based on your medical exception, your medication will either get approved or denied. If approved, you will continue to receive COSENTYX from your specialty pharmacy. If denied, Novartis has a program for eligible commercially covered patients called Covered Until You’re Covered.† This program offers up to 2 years of COSENTYX for free to eligible commercially insured patients while coverage is being pursued.
What is a medical exception?
A medical exception asks an insurance company to reconsider their formulary decision not to include a medication. By submitting a medical exception, you're providing your insurance company with the opportunity to take an individualized approach to their decision-making process to meet your unique needs.
Your doctor must submit a medical exception with supporting information, such as why the alternative medication the insurance plan suggested would not be as effective as COSENTYX for treating your condition, and/or any other reasons you should not take that medication.
What happens if my insurance company denies the medical exception?
If your medical exception is denied, the insurance company will provide a written explanation as to why it was denied and include information about how to request an appeal. Your doctor may file an appeal on your behalf. Please follow up with your doctor to discuss next steps. Novartis has a program for eligible commercially covered patients called Covered Until You’re Covered.† This program offers up to 2 years of COSENTYX for free to eligible commercially insured patients while coverage is being pursued. You can ask your doctor how you can be enrolled in this program if you are eligible.
For more information, you can call 1-844-COSENTYX (1-844-267-3689). Please explain to the representative the information you received from your insurance company about the coverage change for COSENTYX.
If you and your doctor would like COSENTYX® Connect to assist you in determining your eligibility for an appropriate program, please fill out a Service Request Form (SRF) with your doctor.
What is an appeal?
If your medication has been denied, the insurance company must provide an explanation as to why this decision was made and include information about how to request an appeal.
An appeal is a request for your insurance company to reconsider their decision to deny coverage of your medication.
What can I do on my own to stay on COSENTYX?
You may be able to file an exception on your own behalf. Contact your insurance plan to find out how to submit a member medical exception. Then, follow up with your doctor to discuss your plan and get any supporting documents you may need to send with the submission.
Will my $0 co-pay* be affected if my insurance plan doesn't cover COSENTYX?
Your $0 co-pay* program may no longer be accepted in 2021 unless you ask your doctor to submit a medical exception† to your commercial insurance plan and it is approved by the commercial insurance plan. Once your commercial insurance is approved and starts again, you may still be eligible for the $0 co-pay program* as usual.
What should I do if I have more questions?
We are here to help!
If you have a patient support specialist, give them a call first. Or get one now by signing up for COSENTYX® Connect.
Other options:
- You can call 1-844-COSENTYX (1-844-267-3689)
- Reach out to your doctor's office
- Call your insurance plan
- Call your employer
*Program Terms & Conditions: Limitations apply. Valid only for those with private insurance. The COSENTYX Co-pay Program includes the Co-pay Card, Payment Card (if applicable), and Rebate, with a combined annual limit up to $16,000. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, (iii) where the patient's insurance plan reimburses for the entire cost of the drug, or (iv) where product is not covered by patient's insurance. The value of this program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable co‑payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.
†Covered Until You’re Covered Program: Eligible patients must have commercial insurance, a valid prescription for COSENTYX, and a denial of insurance coverage based on a prior authorization request. Program requires the submission of an appeal of the coverage denial within the first 90 days of enrollment in order to remain eligible. Program provides initial 5 weekly doses (if prescribed) and monthly doses for free to patients for up to two years or until they receive insurance coverage approval, whichever occurs earlier. Program is not available to patients whose medications are reimbursed in whole or in part by Medicare, Medicaid, TRICARE, or any other federal or state program. Patients may be asked to re-verify insurance coverage status during the course of the program. No purchase necessary. Program is not health insurance, nor is participation a guarantee of insurance coverage. Limitations may apply. Enrolled patients awaiting coverage for COSENTYX after two years may be eligible for a limited Program extension. Novartis Pharmaceuticals Corporation reserves the right to rescind, revoke, or amend this Program without notice.
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