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Mepolizumab (Nucala®)
BCBS Tennessee·Allergy & Immunology, Pulmonology, Rheumatology +2 more·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
This is a NEW medical policy for Mepolizumab (Nucala®) covering five FDA-approved indications: severe asthma, chronic rhinosinusitis with nasal polyps, COPD, eosinophilic granulomatosis with polyangiitis (EGPA), and hypereosinophilic syndrome (HES). The policy establishes specific prior authorization requirements, documentation standards, prescriber specialty restrictions, and coverage criteria for each indication. Billing teams must implement prior authorization workflows and ensure claims include required clinical documentation before the policy becomes effective.
Action Required
Before December 1, 2026: Billing team must implement prior authorization requirements for all Mepolizumab (Nucala®) claims. (1) Update billing system to require prior authorization submission for all five indications (asthma, CRSwNP, COPD, EGPA, HES). (2) Create prior authorization templates specifying required documentation for each indication: for asthma—blood eosinophil count or systemic corticosteroid dependency plus prior medications tried; for EGPA—eosinophil count, oral corticosteroid use, and disease characteristics; for HES—FIP1L1-PDGFRA fusion gene test results and eosinophil counts; for CRSwNP—nasal imaging/endoscopy details and prior medications; for COPD—COPD symptoms, eosinophil count, and exacerbation history. (3) Verify prescriber specialty matches policy requirements before authorization (allergist/immunologist/pulmonologist for asthma; pulmonologist/allergist for COPD; rheumatologist/pulmonologist/allergist for EGPA; hematologist/allergist/cardiologist for HES; otolaryngologist/allergist for CRSwNP). (4) Flag HES claims for exclusion criteria (secondary HES causes or FIP1L1-PDGFRA kinase-positive status). (5) Configure system for 6-month authorization for asthma and 12-month for EGPA/HES. (6) Educate providers on coverage gaps: Nucala is not covered for acute bronchospasm relief or experimental indications outside the five approved uses. Claims lacking required documentation or failing to meet coverage criteria will be denied.