Summary
Nucala is covered for add-on maintenance treatment of severe asthma with an eosinophilic phenotype, chronic rhinosinusitis with nasal polyps in adults, inadequately controlled COPD with an eosinophilic phenotype, eosinophilic granulomatosis with polyangiitis, and hypereosinophilic syndrome when the approval criteria are met. Coverage is not provided for HES secondary to a non-hematologic cause or for FIP1L1-PDGFRA kinase-positive HES. All other indications are considered experimental/investigational and not medically necessary. The effective date is 2026-12-01.
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What to do
Action · 11 steps
01Future transition 2026-12-01: Submit the documentation the policy requires to start prior authorization review.
02For asthma initial requests, submit chart notes showing the pretreatment blood eosinophil count or dependence on systemic corticosteroids where applicable, and chart notes, medical record documentation or claims history showing previous medications tried with drug, dose, frequency and duration.
03For EGPA initial requests, submit chart notes showing the pretreatment blood eosinophil count or percentage where applicable, and previous medications tried, or the clinical reason to avoid therapy.
04For HES initial requests, submit FIP1L1-PDGFRA fusion gene test results, chart notes showing the pretreatment blood eosinophil count, and previous medications tried.
05For CRSwNP initial requests, submit chart notes showing nasal endoscopy, anterior rhinoscopy or CT details, the Meltzer Clinical Score or endoscopic nasal polyp score where applicable, and previous medications tried, or the clinical reason to avoid therapy.
06For COPD initial requests, submit chart notes showing classic signs or symptoms of COPD, previous medications tried including response to therapy, the absolute blood eosinophil count before starting therapy, and any moderate or severe exacerbations within the past 12 months.
07For continuation requests, submit chart notes supporting improvement in asthma control, beneficial response in EGPA, improvement in HES control with FIP1L1-PDGFRA fusion gene test results, or positive clinical response in CRSwNP and COPD.
08The medication must be prescribed by or in consultation with an allergist/immunologist or pulmonologist for asthma and COPD, an allergist/immunologist or otolaryngologist for CRSwNP, an allergist/immunologist, pulmonologist or rheumatologist for EGPA, and an allergist/immunologist, hematologist or cardiologist for HES.
09Members cannot use Nucala with any other biologic drug or targeted synthetic drug for the same indication.
10If the member is a current smoker or vaper, counsel them on the harmful effects of smoking and vaping on pulmonary conditions and the available cessation options.
11Keep billed quantities within the medication quantity limits: 100 mg every 4 weeks for asthma in patients 12 years and older, 40 mg every 4 weeks for asthma in patients 6 to under 12 years, 100 mg every 4 weeks for COPD and CRSwNP, and 300 mg every 4 weeks as three separate 100-mg injections for EGPA and HES.
Original notice
Mepolizumab (Nucala®)
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