CommercialPrior AuthHigh impact
Mepolizumab (Nucala) (CPB 0897, reviewed 2026-08-05)
Aetna·Allergy & Immunology, Pulmonology, Rheumatology +3 more·Medical Policy
Effective date
Aug 5, 2026
We identified it
Aug 16, 2026
Summary
Aetna has issued a comprehensive clinical policy (CPB 0897) for Mepolizumab (Nucala) covering five indications: severe asthma, eosinophilic granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome (HES), chronic rhinosinusitis with nasal polyposis (CRSwNP), and COPD. All mepolizumab prescriptions require precertification through Aetna's specialty pharmacy program, and coverage is restricted to specific medical specialties based on indication. The policy establishes detailed clinical criteria for initial approval and continuation of therapy, with mandatory trial of preferred biologics in certain scenarios.
Action Required
Effective immediately (policy reviewed 2026-08-05): (1) Billing team must implement mandatory precertification requirement for ALL mepolizumab (Nucala) claims by calling (866) 752-7021 or faxing (888) 267-3277 before claim submission. (2) Update billing system to enforce specialty prescriber requirements: asthma claims must come from allergist/immunologist or pulmonologist; EGPA from allergist/immunologist, pulmonologist, or rheumatologist; HES from allergist/immunologist, hematologist, or cardiologist; CRSwNP from allergist/immunologist or otolaryngologist; COPD from pulmonologist or allergist/immunologist. (3) Ensure all Aetna mepolizumab authorization requests include documented baseline blood eosinophil counts and proof of prior biologic therapy failure or specific clinical criteria per indication. (4) For asthma: verify member is on high-dose ICS plus additional controller; for COPD: verify eosinophil count ≥300 cells/microliter and at least 2 moderate or 1 severe exacerbation in past 12 months. (5) Cross-reference all HES claims against exclusion criteria (HES secondary to non-hematologic causes or FIP1L1-PDGFRA kinase-positive). (6) Update encounter templates to capture required documentation for each indication. (7) Train providers on age restrictions: asthma/COPD/CRSwNP (age 18+), EGPA (age 18+), HES (age 12+), asthma biologic-naïve pathway (age 6+). Claims lacking required precertification or failing to meet specialty/clinical criteria will be denied.