Diagnosis: Severe Scalp Psoriasis

Treatment: medication Cosentyx

The insurer denied coverage for medication Cosentyx

The denial is overturned

The patient is a male with a history of severe scalp psoriasis and androgenic alopecia. The patient has failed prior therapy with Taltz and Xeljanz. According to the submitted documentation, the patient has been successfully treated with Cosentyx for his psoriasis. The requested medication is continuation of Cosentyx.

The patient has failed therapy with Xeljanz (used for his alopecia) as well as Taltz. He has been successfully treated and maintained on Cosentyx for his psoriasis since without any reported adverse effects and excellent clinical results. In a Cochrane review of treatment of psoriasis, it is apparent the no agent is successful at a level that one can assume a lack of need of successive trials of different agents. This is supported in this patient who has already being tried on 2 different biologic agents that were not effective. In contrast, Cosentyx, has been effective since starting. It is thus not clinically appropriate to now try another agent simply because it is available. In sum, based on the documentation provided and the standard of care, the decision is overturned and the use of Cosentyx is supported.

The insurer's denial of coverage for Formulary Exception for the medication Cosentyx is overturned.