Drug Prior Authorization Form Secukinumab (Cosentyx) Page 2

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STEP 4: SUBMISSION. SIGN AND FAX TO: NAVITUS PRIOR AUTHORIZATION AT
Prescriber Signature:________________________________________________ Date:____________
If patient meets criteria, please allow 2 business days for processing
If criteria not met, submit chart documentation with form citing complex medical circumstances
If approved, coverage allowed for 3 months/1 year as indicated above (subject to formulary changes)
For questions, please call Navitus at 866-333-2757.
12/17/2015
Version 1.0

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