HCPCS
J3247
1 mg = 1 unit (IV only)
Phase 1
Identify what you're billing
Confirm the route (IV vs SC), benefit channel, indication, and dose before building the claim.
IV vs. SC — J3247 vs. pharmacy NDC FDA verified May 2026
Same molecule, two distinct billing pathways — getting this wrong is the #1 Cosentyx claim error.
Cosentyx is the same antibody (secukinumab) in two formulations. The dominant utilization — roughly 95% of Cosentyx prescriptions — is the subcutaneous (SC) formulation, which patients self-inject at home using a Sensoready pen, UnoReady pen, or prefilled syringe. SC Cosentyx bills through the pharmacy benefit (Part D for Medicare; commercial Rx benefit otherwise) using the NDC. The intravenous (IV) formulation, FDA approved October 6, 2023, is administered in office or HOPD and bills through the medical benefit under HCPCS J3247 (effective July 1, 2024). IV is approved only for psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis — not for plaque psoriasis or HS as of Q2 2026.
| Cosentyx IV (J3247) | Cosentyx SC (pharmacy) | |
|---|---|---|
| HCPCS | J3247 — eff. Jul 1, 2024 | None. Bills via NDC under pharmacy benefit. (J3590 if rare medical-benefit SC.) |
| FDA approval | October 6, 2023 | January 21, 2015 (initial PsO indication) |
| Form | 125 mg / 5 mL (25 mg/mL) SDV — dilute for infusion | 75 mg/0.5 mL PFS · 150 mg/mL Sensoready · 300 mg/2 mL UnoReady / PFS |
| NDC (primary) | 0078-1168-61 (IV vial) | 0078-0639-41 (300 mg via 2×150 mg Sensoready) · 0078-1070-68 (300 mg UnoReady) |
| Dose | 6 mg/kg loading × 1, then 1.75 mg/kg q4wk (max 300 mg/dose) | 300 mg weeks 0–4, then q4wk (PsO/PsA/AS/nr-axSpA/HS) |
| Route | IV infusion, 30 min | SC self-injection |
| Benefit channel | Medical (Part B / commercial medical) | Pharmacy (Part D / commercial Rx) |
| Approved indications | PsA, AS, nr-axSpA only | PsO (adult + ped), PsA (adult + ped), AS, nr-axSpA, HS, ERA (ped) |
| Admin CPT | 96365 (1 hr therapeutic IV) | Not applicable (patient self-injects) |
| Q2 2026 ASP+6% | $18.042/mg | WAC ~$6,800 / 300 mg dose; net price varies by PBM contract |
| Site of care | Office, AIC, HOPD, home infusion | Patient home (mail-order specialty pharmacy) |
Practical decision tree: Is the patient receiving the dose in your office/HOPD via an IV
infusion of secukinumab from a 125 mg/5 mL vial? → J3247, medical benefit. Is the
patient picking up Sensoready / UnoReady pens at a specialty pharmacy and self-injecting at home? →
Pharmacy benefit, NDC, no J3247. Is the patient self-injecting in your office under nurse
observation? → Almost always still pharmacy benefit; check payer guidance before billing J3590.
IV not approved for plaque PsO or HS as of Q2 2026. Cosentyx IV (J3247) is FDA-approved only
for PsA, AS, and nr-axSpA. Do not bill J3247 for plaque psoriasis or hidradenitis suppurativa — the
indication isn't on label and the claim will deny. Plaque PsO and HS patients use the SC formulation through
the pharmacy benefit.
Don't use J3247 for SC Cosentyx. J3247's HCPCS descriptor is explicit: "Injection,
secukinumab, intravenous, 1 mg." The IV qualifier is part of the code definition. SC Cosentyx
administered under the medical benefit (rare) bills as J3590 (unclassified biologic) plus the SC NDC, not
J3247.
Dosing & unit math FDA label current
Per FDA prescribing information — SC and IV regimens.
Subcutaneous (pharmacy benefit) — ~95% of utilization
| Indication | Loading | Maintenance | Notes |
|---|---|---|---|
| Plaque psoriasis (adult) | 300 mg SC at weeks 0, 1, 2, 3, 4 | 300 mg SC every 4 weeks | 150 mg may be acceptable for some patients |
| Plaque psoriasis (pediatric ≥6 yr) | Weight-based: <50 kg = 75 mg; ≥50 kg = 150 mg at weeks 0, 1, 2, 3, 4 | Same dose q4wk | Use 75 mg PFS (NDC 0078-1056-97) |
| Psoriatic arthritis (adult) | 150 or 300 mg SC at weeks 0, 1, 2, 3, 4 | Same dose q4wk | 300 mg recommended for concurrent moderate-severe plaque PsO or inadequate TNFi response |
| Ankylosing spondylitis | 150 mg SC at weeks 0, 1, 2, 3, 4 (with or without loading) | 150 mg q4wk (may up-titrate to 300 mg) | — |
| nr-axSpA | 150 mg SC at weeks 0, 1, 2, 3, 4 (with or without loading) | 150 mg q4wk | — |
| HS (added Oct 2023) | 300 mg SC at weeks 0, 1, 2, 3, 4 | 300 mg q4wk; may up-titrate to q2wk if response inadequate | HS often requires the q2wk maintenance escalation |
| PsA (pediatric ≥2 yr) / ERA (≥4 yr) | Weight-based: 75 mg if <50 kg; 150 mg if ≥50 kg, at weeks 0, 1, 2, 3, 4 | Same dose q4wk | Pediatric pen forms available |
Intravenous (medical benefit, J3247) — PsA / AS / nr-axSpA only
FDA-labeled IV dose:
"6 mg/kg as an intravenous infusion at week 0, followed by 1.75 mg/kg every 4 weeks thereafter. The maximum dose per infusion is 300 mg."
- Loading dose: 6 mg/kg IV at week 0 (single dose)
- Maintenance: 1.75 mg/kg IV every 4 weeks, capped at 300 mg per dose
- Infusion time: ~30 minutes
- Dilution: withdraw required volume from 125 mg/5 mL vial(s); dilute in 250 mL 0.9% NaCl or D5W
- 1 mg = 1 unit: bill J3247 units = total mg administered (after weight-based calc, capped at 300)
Worked example — IV PsA patient, 80 kg
# Loading dose, week 0: 6 mg/kg × 80 kg = 480 mg
Capped at 300 mg/dose (FDA max). Bill 300 units of J3247.
Vials needed: 3 × 125 mg = 375 mg available; 75 mg waste → bill JW for 75 units.
# Maintenance dose, week 4 onward: 1.75 mg/kg × 80 kg = 140 mg
Below 300 mg cap. Bill 140 units of J3247.
Vials needed: 2 × 125 mg = 250 mg available; 110 mg waste → bill JW for 110 units.
# 12-month total IV doses: 1 loading + 12 maintenance = 13 doses
# Year-1 J3247 units (drug administered): 300 + (12 × 140) = 1,980 units
Capped at 300 mg/dose (FDA max). Bill 300 units of J3247.
Vials needed: 3 × 125 mg = 375 mg available; 75 mg waste → bill JW for 75 units.
# Maintenance dose, week 4 onward: 1.75 mg/kg × 80 kg = 140 mg
Below 300 mg cap. Bill 140 units of J3247.
Vials needed: 2 × 125 mg = 250 mg available; 110 mg waste → bill JW for 110 units.
# 12-month total IV doses: 1 loading + 12 maintenance = 13 doses
# Year-1 J3247 units (drug administered): 300 + (12 × 140) = 1,980 units
Required pre-infusion / pre-injection checks
- TB screening before initiation (latent TB testing per FDA label)
- No active infection
- For IBD patients: counsel on risk of IBD exacerbation; monitor closely
- Live vaccine status (avoid live vaccines during therapy)
- For IV: weight verification within 30 days for accurate mg/kg calc
NDC reference FDA NDC Directory verified May 2026
Novartis labeler 0078. IV vial separate from all SC presentations.
| NDC (10-digit) | NDC (11-digit) | Formulation | Use |
|---|---|---|---|
0078-1168-61 |
00078-1168-61 |
125 mg / 5 mL (25 mg/mL) IV vial | IV (J3247) — single-dose, dilute for infusion |
0078-1056-97 |
00078-1056-97 |
75 mg / 0.5 mL PFS, single | SC, pediatric PsO <50 kg (pharmacy benefit) |
0078-1056-99 |
00078-1056-99 |
75 mg / 0.5 mL PFS, 2-pack | SC, pediatric PsO loading (pharmacy benefit) |
0078-0639-97 |
00078-0639-97 |
150 mg / mL PFS, single | SC adult, 150 mg dose (pharmacy benefit) |
0078-0639-41 |
00078-0639-41 |
150 mg / mL Sensoready pen, 2-pack (300 mg dose) | SC adult, 300 mg dose via two pens (pharmacy benefit) |
0078-1070-68 |
00078-1070-68 |
300 mg / 2 mL UnoReady pen | SC adult, 300 mg in single pen (pharmacy benefit) |
0078-1070-96 |
00078-1070-96 |
300 mg / 2 mL PFS | SC adult, 300 mg PFS (pharmacy benefit) |
11-digit NDC required on most claim forms. Pad the labeler segment to 5 digits: 00078-1168-61
for IV. Use the
N4 qualifier in CMS-1500 Box 24A and UB-04 Box 43. Many sources and even pharmacy
labels show the 10-digit form (0078-1168-61) — these reference the same product.
Only the IV vial (0078-1168-61) bills under J3247. All other NDCs above are SC presentations
and bill through the pharmacy benefit. Do not pair J3247 with an SC NDC on a medical claim — the
mismatch will trigger an automatic edit.
Phase 2
Code the claim
IV admin code 96365 (not chemo). Modifiers JZ/JW for vial waste. ICD-10 must match the indication's approved route.
Administration codes CPT verified May 2026
Cosentyx IV is non-chemotherapeutic — use therapeutic IV codes, not chemo.
| Code | Description | When to use |
|---|---|---|
96365 |
IV infusion, for therapy/prophylaxis/diagnosis; initial, up to 1 hour | Primary IV admin code. Cosentyx IV infuses over ~30 minutes — well within the 1-hour window. |
96366 |
IV infusion, for therapy/prophylaxis/diagnosis; each additional hour | Typically NOT billed — 30-min infusion fits within the first hour. |
96413 / 96415 |
Chemotherapy IV administration codes | Not appropriate. Secukinumab is non-chemotherapeutic. |
96372 |
Therapeutic SC/IM injection | Rarely billed for SC Cosentyx (patient typically self-injects at home). Use only when SC Cosentyx is administered in office under medical benefit (J3590 + NDC). |
S9329 + 99601 / 99602 |
Home infusion HCPCS + administration CPT | Home IV infusion supported through specialty home-infusion vendors; verify payer coverage (most steer to AIC instead). |
Why not chemo: some payers historically denied 96413 for non-chemotherapeutic monoclonal
antibodies. Cosentyx IV (and the entire IL-17/IL-23 class) bills under 96365. Don't be tempted to bill chemo
admin codes for the higher reimbursement — the documentation won't support it.
96372 is rarely billed for Cosentyx SC. The SC formulation is patient self-injected at home
in >95% of cases. If the patient receives the SC dose in your office under nurse observation, the dose is
typically still being filled through the pharmacy benefit (the patient's own Sensoready/UnoReady), and no
96372 medical claim is appropriate. Office stocking and administering of SC Cosentyx through the medical
benefit is unusual and requires payer-specific verification.
Modifiers CMS verified May 2026 — verify JZ list
JZ — whole-vial use, no waste
Effective July 1, 2023, CMS requires JZ on all claims for single-dose container drugs when no drug is discarded — but only for codes on the CMS single-dose container list. Cosentyx IV is supplied in a 125 mg single-dose vial; whole-vial use is rare because doses are weight-based. JZ applies only when the patient's calculated dose is an exact multiple of 125 mg with no discard. Verify against the current CMS single-dose container list at billing time.
JW — documented wastage (more common for Cosentyx IV)
Because Cosentyx IV doses are weight-based and the vial size is 125 mg, most maintenance doses (1.75 mg/kg) and the loading dose (6 mg/kg, capped at 300 mg) leave residual drug in the last vial. Bill JW with the wasted units on a separate line. Document the wastage in the medical record (vial size, calculated dose, wasted mg).
Example: 80 kg PsA patient, maintenance 1.75 mg/kg = 140 mg dose.
- Vials needed: 2 × 125 mg = 250 mg available
- Administered: 140 mg → bill J3247 with 140 units, no modifier or JZ if on list
- Wasted: 110 mg → bill J3247 with 110 units + JW on a separate line
- Total: 250 units billed across two lines
JW documentation must include: reason for waste (single-dose vial, dose-based on weight),
vial size, calculated dose, mg administered, mg wasted. Many payers audit JW claims; failing to document
the math properly results in recoupment.
Modifier 25 — situational
Use modifier 25 on the E/M code when a significant, separately identifiable evaluation and management service is performed on the same day as the infusion. Routine pre-infusion vitals/screening is bundled.
340B modifiers (JG, TB)
For 340B-acquired Cosentyx IV, follow your MAC's current 340B modifier policy. Most 340B-eligible facilities access secukinumab through specialty distributors with 340B pricing.
ICD-10-CM diagnosis codes FY2026 verified May 2026
Cosentyx covers a broad inflammatory/immunologic diagnosis space — but IV is approved only for PsA, AS, nr-axSpA.
| ICD-10 | Description | SC eligible? | IV eligible? (J3247) |
|---|---|---|---|
L40.0 | Psoriasis vulgaris (plaque PsO) | Yes | NO — IV not approved for plaque PsO |
L40.50 | Arthropathic psoriasis, unspecified | Yes | Yes (PsA) |
L40.51 | Distal interphalangeal psoriatic arthropathy | Yes | Yes |
L40.52 | Psoriatic arthritis mutilans | Yes | Yes |
L40.53 | Psoriatic spondylitis | Yes | Yes |
L40.54 | Psoriatic juvenile arthropathy | Yes (ped ≥2 yr) | Adults only on label |
L40.59 | Other psoriatic arthropathy | Yes | Yes |
M45.0–M45.9 | Ankylosing spondylitis (by spinal region) | Yes | Yes |
M46.80–M46.89 | Other specified inflammatory spondylopathies | Yes (nr-axSpA) | Yes (nr-axSpA) |
M46.9 | Unspecified inflammatory spondylopathy | Acceptable for nr-axSpA documentation | Acceptable for nr-axSpA |
L73.2 | Hidradenitis suppurativa | Yes (added Oct 2023) | NO — IV not approved for HS |
M08.1 | Juvenile ankylosing spondylitis (ERA) | Yes (ped ≥4 yr) | Adults only on label |
M08.0–M08.99 | Other juvenile arthritis variants | Per pediatric indications | Adults only on label |
IV indication discipline: Cosentyx IV (J3247) is FDA-approved only for PsA (L40.5x), AS
(M45.x), and nr-axSpA (M46.8x / M46.9). Submitting J3247 with L40.0 (plaque PsO) or L73.2 (HS) will deny.
Patients with these indications use SC Cosentyx through the pharmacy benefit.
Pediatric IV not on label: Cosentyx IV is approved for adults only as of Q2 2026. Pediatric
Cosentyx (PsO ≥6 yr, PsA ≥2 yr, ERA ≥4 yr) uses the SC formulation with weight-based dosing.
Site of care & place of service Verified May 2026
Cosentyx IV is a 30-minute infusion that fits any ambulatory setting cleanly. Major commercial payers (UnitedHealthcare, Cigna, Anthem) increasingly run site-of-care utilization-management programs that steer non-emergent IV biologics away from hospital outpatient (HOPD) toward freestanding ambulatory infusion centers (AICs) or home infusion. SC Cosentyx is not subject to medical-benefit POS rules — it's dispensed by specialty pharmacy to the patient's home.
| Setting | POS | Claim form | Electronic |
|---|---|---|---|
| Physician office (IV) | 11 | CMS-1500 | 837P |
| Ambulatory infusion suite (IV) | 49 | CMS-1500 | 837P |
| Hospital outpatient (IV) | 19 or 22 | UB-04 / CMS-1450 | 837I |
| Patient home (IV) | 12 | CMS-1500 (with home-infusion HCPCS) | 837P |
| Patient home (SC, self-inject) | n/a (pharmacy benefit) | NCPDP claim from specialty pharmacy | NCPDP D.0 |
Site-of-care policies tightening: UHC, Cigna, and Anthem increasingly require non-emergent
IV biologic infusions (including Cosentyx IV) to be administered at the patient's home or a freestanding
AIC, not HOPD. Confirm site-of-care precertification before scheduling Cosentyx IV in a hospital outpatient
department — HOPD claims may be redirected or denied.
Claim form field mapping Verified May 2026
CMS-1500 / 837P (physician office, AIC; POS 11/49) for IV. Pharmacy NCPDP claim for SC.
IV claim (J3247) — CMS-1500 / 837P
| Information | CMS-1500 box | Notes |
|---|---|---|
| NPI | 17b | Rendering provider |
| NDC qualifier + 11-digit NDC + UoM + qty | 24A shaded area | Format: N400078116861ML5 (per vial) |
| HCPCS J3247 + admin CPT 96365 | 24D | Each on its own line. Add JW line if waste. |
| Drug units (mg) | 24G | Administered mg. Add separate JW line for wasted mg. |
| Patient weight | Box 19 / NTE segment | Critical — supports the weight-based dose calculation |
| ICD-10 | 21 | L40.5x (PsA), M45.x (AS), or M46.8x / M46.9 (nr-axSpA) |
| PA number | 23 | Required by virtually all payers |
SC dispensing (pharmacy benefit) — NCPDP D.0
SC Cosentyx is dispensed by a specialty pharmacy and adjudicated through the pharmacy benefit (Part D for Medicare; commercial Rx benefit otherwise). The specialty pharmacy submits an NCPDP claim with the SC NDC, days supply, and DAW code. The prescribing provider's office is not involved in claim submission for SC Cosentyx beyond writing the Rx and supporting the PA.
Form references: NUCC (CMS-1500).
Phase 3
Get paid
Universal PA. TNFi step therapy for PsA/AS. SC pharmacy adjudicates differently than IV medical.
Payer policy snapshot Reviewed May 2026
Universal prior authorization. Step therapy through TNF inhibitors common for PsA/AS; PsO step therapy variable.
| Payer | PA? | Step therapy | SC vs IV | Re-auth |
|---|---|---|---|---|
| UnitedHealthcare Secukinumab medical/pharmacy policy |
Yes | TNFi trial required for PsA/AS (adalimumab biosimilar or etanercept). PsO step variable. | SC pharmacy benefit; IV under site-of-care UM | 12 mo w/ documented response |
| Aetna CPB 0658 (biologics for inflammatory disease) |
Yes | TNFi failure required for PsA/AS. HS = trial of adalimumab (Humira/biosimilar) typically required first. | Both routes covered per indication | w/ documented response |
| Anthem / Carelon Inflammatory disease biologics policy |
Yes | TNFi step for PsA/AS; PsO step variable by plan | Site-of-care UM for IV (steer to AIC/home) | w/ disease stability |
| Cigna Cosentyx coverage policy |
Yes | TNFi step (PsA/AS); HS requires adalimumab trial | Strong SC preference; IV requires medical necessity for failure of SC | 12 mo |
| BCBS FEP 5.21.07 (interleukin inhibitors) |
Yes | TNFi step for PsA/AS; PsO some plans first-line | Both routes covered | w/ documented response |
Key finding — SC vs IV preference: several major payers (Cigna, UHC) explicitly prefer
SC Cosentyx and require documented failure of SC before approving the IV formulation. For most patients, the
IV pathway is reserved for those who can't or won't self-inject, or who have documented adherence/response
issues with SC. The IV pathway is also more expensive to administer (medical benefit + admin code + facility
fee), so payers steer SC.
TNFi step therapy is near-universal for PsA/AS. Most plans require trial and failure (or
documented intolerance/contraindication) to a TNF inhibitor — typically an adalimumab biosimilar or
etanercept — before approving Cosentyx. For HS, payers commonly require Humira/adalimumab biosimilar
trial first (Humira was the first FDA-approved biologic for HS). For plaque PsO, step therapy is more variable
— some plans allow Cosentyx first-line.
What to document for approval
- Confirmed diagnosis with ICD-10 specific to indication (avoid unspecified codes where possible)
- For PsA/AS: prior TNFi trial(s) with dates, dose, duration, reason for discontinuation
- For HS: prior adalimumab/biosimilar trial (most plans)
- TB screening (latent TB test) results within 12 months
- For IV: documented rationale for IV over SC (failure of SC, adherence concerns, or new start preferring IV loading)
- For pediatric: age, weight, indication appropriate to label
- No active serious infection
Medicare reimbursement CMS Q2 2026 (live)
Quarterly ASP from CMS Part B Drug Pricing File. Refreshes automatically each quarter.
Q2 2026 payment snapshot — J3247 (IV)
Effective April 1 – June 30, 2026 · Based on 4Q25 ASP submissions
ASP + 6%
$18.042
per mg / per unit
300 mg dose
$5,412.60
300 units × ASP+6%
After sequestration
~$5,304
~2% reduction (actual paid)
Annualized IV cost (max-dose patient): 1 loading + 12 maintenance doses. Loading = 300 mg
($5,412.60); maintenance = 1.75 mg/kg (varies by weight, capped at 300 mg). For an 80 kg patient: 12 ×
$2,525.88 (140 mg) = $30,310.56 + $5,412.60 loading = ~$35,723/year in J3247 drug spend
before sequestration. Add admin (96365) and facility/AIC fees. SC Cosentyx (pharmacy benefit) WAC
is approximately $6,800 per 300 mg dose; net price varies by PBM rebate.
Part B vs Part D
For Medicare beneficiaries: Cosentyx IV (J3247) is paid under Part B (medical benefit). SC Cosentyx is paid under Part D (prescription drug benefit). The patient's out-of-pocket exposure differs significantly — Part B coinsurance is 20% (after deductible) with no annual cap unless covered by Medigap or other secondary; Part D has plan-specific cost-sharing tiers and (post-2025) a $2,000 annual OOP cap under the Inflation Reduction Act.
Coverage
No NCD specific to secukinumab. Coverage falls under the generic drug-coverage LCD framework (e.g., LCD L33394). All MACs cover J3247 for FDA-approved on-label IV indications (PsA, AS, nr-axSpA). Bill with appropriate ICD-10.
Code history
- 2015 — FDA approval (SC, plaque psoriasis); SC bills under pharmacy benefit, no medical HCPCS needed
- October 6, 2023 — FDA approval of IV formulation for PsA/AS/nr-axSpA
- October 2023 — HS indication added (SC only)
- Pre-July 2024 — IV claims under unclassified
J3590with the NDC - July 1, 2024 —
J3247permanent code, "Injection, secukinumab, intravenous, 1 mg" (1 mg = 1 unit)
Patient assistance — Cosentyx Connect Novartis verified May 2026
- Cosentyx Connect: 1-844-COSENTYX (1-844-267-3689) — central support hub for benefits investigation, PA, copay, and patient education
- Cosentyx Connect Co-Pay Program: commercial patients only. As low as $0 copay; up to $16,000/year drug benefit + up to $1,950/year ($150 per infusion) IV admin support. Excludes Medicare, Medicaid, TRICARE, VA, and other federal program patients.
- Bridge Program ("COVERED Until You're COVERED"): up to 2 years free SC Cosentyx while coverage is being pursued (eligibility criteria apply)
- Novartis Patient Assistance Foundation (NPAF): free product for uninsured / government-insured patients meeting income limits (typically ≤500% FPL)
- Free Trial Offer: a starter supply available through Cosentyx Connect for new starts pending coverage
- Web: cosentyx.com · cosentyxhcp.com
Need to model what a specific patient will actually pay after copay assistance, deductible, coinsurance,
and OOP max? Run a CareCost Estimate — J3247 (IV) and SC pharmacy
benefit pre-loaded.
Copay program excludes federal program patients. Medicare, Medicaid, TRICARE, VA, CHIP, and
other government-insured patients are not eligible for Cosentyx Connect Co-Pay. For these patients, route
to NPAF (income-based free drug) or independent disease-specific foundations (e.g., Patient Access Network
Foundation, HealthWell, PSC Partners) for copay assistance.
Phase 4
Fix problems
SC vs IV mix-ups, J3247-vs-J3590 vintage errors, indication-route mismatches, and TNFi step are the top denials.
Common denials & how to fix them
| Denial reason | Common cause | Fix |
|---|---|---|
| J3247 billed for SC Cosentyx | SC dose mistakenly submitted under medical benefit with J3247 | SC Cosentyx is pharmacy benefit. Reroute through specialty pharmacy. If administered in office under medical benefit (rare), use J3590 + SC NDC. |
| J3247 denied for plaque PsO or HS | IV billed for non-IV-approved indication (plaque PsO L40.0 or HS L73.2) | Cosentyx IV is approved only for PsA, AS, nr-axSpA. For PsO/HS patients, switch to SC Cosentyx (pharmacy benefit). |
| J3590 used post-July 2024 | Unclassified code submitted instead of J3247 for IV after permanent code effective | Resubmit with J3247 for any IV date of service on or after July 1, 2024. Pre-July 2024 IV claims correctly used J3590 + NDC. |
| Step therapy — missing TNFi failure | PsA/AS PA submitted without documented TNF-inhibitor inadequate response or intolerance | Submit prior TNF treatment history (adalimumab/biosimilar, etanercept, infliximab) with dates, doses, reason for failure. Most payers require this for PsA/AS. |
| Step therapy — HS without adalimumab trial | HS PA submitted without prior Humira/adalimumab biosimilar trial | Document adalimumab failure or intolerance. Humira was first-approved HS biologic; most plans require it before Cosentyx for HS. |
| Wrong admin code (96413) | Chemo admin code billed for non-chemo Cosentyx IV | Resubmit with 96365 (therapeutic IV, 1 hour). Always 96365 for secukinumab. |
| JW modifier denied / unsupported | Wastage billed without supporting documentation | Document vial size (125 mg), patient weight, calculated dose (1.75 mg/kg or 6 mg/kg), administered mg, wasted mg. Resubmit JW with documentation in NTE. |
| Site-of-care denial (HOPD) | UHC/Cigna/Anthem site-of-care UM redirects HOPD infusion to AIC or home | Obtain site-of-care precertification before scheduling. Schedule patient at freestanding AIC or arrange home infusion through approved vendor. |
| NDC format / mismatch | SC NDC submitted with J3247, or 10-digit submitted when payer requires 11-digit | For J3247 IV claims, only use IV NDC 00078-1168-61 (11-digit). Pharmacy-benefit SC NDCs do not pair with J3247. |
| Pediatric IV denial | Cosentyx IV billed for pediatric patient | IV is adult-only on label. Switch pediatric patient to SC formulation with weight-based dosing (75 mg if <50 kg; 150 mg if ≥50 kg). |
| TB screening not documented | PA missing latent TB test result | Submit TB test (interferon-gamma release assay or PPD) within 12 months of initiation. If positive, submit treatment plan for latent TB. |
| IBD exacerbation flag | Patient with concurrent IBD (Crohn's, UC) flagged for caution | Document IBD status, prior flare history, and clinical justification for IL-17 use despite IBD risk. Cosentyx is not first-choice in IBD — an IL-23 (Skyrizi, Tremfya) may be preferred for psoriatic disease + IBD. |
Frequently asked questions
What is the HCPCS code for Cosentyx?
Cosentyx (secukinumab) intravenous formulation is billed under HCPCS J3247 — "Injection,
secukinumab, intravenous, 1 mg" — effective July 1, 2024. Each milligram equals one billable unit, so
the standard 300 mg IV dose is billed as 300 units. J3247 applies to the IV route ONLY.
Subcutaneous Cosentyx (the dominant utilization, ~95%) bills through the pharmacy benefit using the NDC, not
J3247.
Does J3247 apply to subcutaneous Cosentyx?
No. J3247's HCPCS descriptor is explicit: "Injection, secukinumab, intravenous, 1 mg." Subcutaneous
Cosentyx (Sensoready pen, UnoReady pen, prefilled syringe) is patient-administered at home and bills through
the pharmacy benefit using the NDC. In the rare case where SC Cosentyx is administered in office under the
medical benefit, use J3590 (unclassified biologic) plus the NDC; do not use J3247.
When did J3247 become effective?
July 1, 2024. Before that date, IV Cosentyx (FDA approved October 6, 2023) was billed under unclassified
J3590 with the NDC. J3247 is a permanent code; legacy claims under J3590 with dates of service
before July 1, 2024 should not be reopened to J3247.
How is Cosentyx dosed?
Subcutaneous (most patients): 300 mg SC at weeks 0, 1, 2, 3, 4 (loading), then 300 mg SC every 4 weeks (plaque psoriasis adult). For PsA / AS / nr-axSpA / HS, the dose is 150 or 300 mg SC weekly weeks 0–4, then every 4 weeks. Intravenous (PsA / AS / nr-axSpA only, approved Oct 6, 2023): 6 mg/kg IV loading dose × 1, then 1.75 mg/kg IV every 4 weeks (maximum 300 mg per dose). IV is NOT approved for plaque psoriasis or HS as of Q2 2026.
What is the administration code for IV Cosentyx?
CPT 96365 — "Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up
to 1 hour." Cosentyx IV infuses over 30 minutes, fitting within the first hour. Secukinumab is
non-chemotherapeutic, so 96413 (chemo administration) is NOT appropriate. 96366 (each additional hour)
typically does not apply.
Are there biosimilars for Cosentyx?
No. As of Q2 2026, there are no FDA-approved biosimilars for secukinumab. The Cosentyx patent estate runs through 2028 and beyond; substitution pressure is meaningfully lower than for adalimumab (Humira) or ustekinumab (Stelara), both of which now face multiple biosimilar competitors. Payer step therapy still applies — most plans require trial/failure of a TNF inhibitor (typically an adalimumab biosimilar) before approving Cosentyx for PsA or AS.
Does Cosentyx have a boxed warning?
No. Cosentyx does NOT carry an FDA boxed warning. Class warnings (in the FDA prescribing information but not boxed): serious infections, tuberculosis reactivation (TB screening required before initiation), inflammatory bowel disease exacerbation (caution in IBD patients), and hypersensitivity reactions including anaphylaxis.
What is the Medicare reimbursement for J3247?
For Q2 2026, the Medicare Part B payment limit for J3247 is $18.042 per mg (ASP + 6%). The standard 300 mg IV dose reimburses at approximately $5,412.60 before sequestration. ASP is updated quarterly by CMS. Note: this is the IV reimbursement only; SC Cosentyx is paid through Part D (pharmacy benefit), not Part B.
Which Cosentyx indications are SC vs IV?
Subcutaneous (all FDA-approved indications): plaque psoriasis (adult and pediatric ≥6 yr), psoriatic arthritis (adult and pediatric ≥2 yr), ankylosing spondylitis, non-radiographic axial spondyloarthritis, hidradenitis suppurativa (added Oct 2023), and enthesitis-related arthritis (pediatric ≥4 yr). Intravenous (approved Oct 6, 2023): PsA, AS, and nr-axSpA only. IV is NOT approved for plaque psoriasis, HS, or pediatric indications as of Q2 2026.
How does Cosentyx compare to other IL-17 / IL-23 inhibitors?
Cosentyx (secukinumab) is an anti-IL-17A monoclonal antibody. Taltz (ixekizumab) is also anti-IL-17A, SC only. Bimzelx (bimekizumab) targets both IL-17A and IL-17F, SC only. The IL-23 class — Tremfya (guselkumab), Skyrizi (risankizumab) — targets the p19 subunit of IL-23 and now offers IV formulations for IBD (Tremfya for CD/UC; Skyrizi for CD). Stelara (ustekinumab) targets the p40 subunit of IL-12/23 and now faces multiple biosimilars (2024–2025 launches). Cosentyx is the only IL-17A with an IV formulation as of Q2 2026.
Reference
Sources & methodology
Every claim on this page is sourced. Methodology and review history below.
Source documents
- FDA — COSENTYX (secukinumab) Prescribing Information
- DailyMed — COSENTYX label search
- Cosentyx.com — patient site
- Cosentyx HCP — provider site
- CMS — Medicare Part B Drug ASP Pricing File
- CMS — HCPCS quarterly update file
- CMS — JW Modifier and JZ Modifier policy
- AAPC — HCPCS J3247
- Aetna Clinical Policy Bulletin 0658 — Biologics for Inflammatory Disease
- UnitedHealthcare — Provider portal (medical & pharmacy policies)
- Cigna — Coverage policies
- FDA National Drug Code Directory
- FDA Press Announcements — Cosentyx HS approval (October 2023)
- Novartis Pharmaceuticals Corporation
About this page
We maintain this page as a living reference. Medicare ASP pricing is bound to our underlying CareCost data layer and refreshes automatically when CMS publishes new quarterly files. Coding and policy content is reviewed at least quarterly and updated whenever a source document changes.
Found an error? Email hello@carecostestimate.com.
Refresh cadence
| Element | Cadence | How it's refreshed |
|---|---|---|
| Medicare ASP pricing (J3247) | Quarterly | Auto-bound to CareCost ASP layer; updates on CMS file release. |
| Payer policies (UHC, Aetna, Cigna, Anthem, BCBS) | Semi-annual | Manual review against published payer policy documents. |
| HCPCS / CPT / modifier rules + CMS single-dose container list | Quarterly | JZ/JW applicability for J3247 specifically requires more frequent verification. |
| NDC, dosing, FDA label | Event-driven | Tied to manufacturer document version + FDA label revision date. |
| SC pharmacy-benefit pricing (WAC / net) | Annual | WAC changes reviewed annually; PBM net pricing varies and is not published. |
| Biosimilar landscape | Quarterly | Watch for FDA biosimilar approvals (none Q2 2026; expected post-2028). |
Reviewer
Pending SME review. This page is staff-authored from primary sources (FDA, CMS, manufacturer,
payer documents — all linked above). Final review by our SME, Catherine Rose (CPC), is in progress.
Until that review is complete, treat this as a draft reference and verify each cited source for high-stakes
claims.
Change log
- — Initial publication. ASP data: Q2 2026 (J3247 = $18.042/mg). IV approved Oct 6, 2023; J3247 effective July 1, 2024. HS indication added Oct 2023 (SC only). No biosimilars Q2 2026. Payer policies: UHC, Aetna CPB 0658, Cigna, Carelon/Anthem, BCBS FEP 5.21.07. TNFi step therapy required for PsA/AS at most major payers.
Methodology
Every claim on this page is sourced inline. Pricing reflects the current CMS Part B Drug ASP Pricing File. Payer policies are read directly from each payer's published medical/pharmacy policy documents. We do not paraphrase from billing-software vendor blogs. The IV vs SC benefit-channel distinction is a frequent claim error for Cosentyx; we make it explicit in multiple sections rather than burying it in a footnote.