By Counterforce Health Team in Nucala (mepolizumab) —

Getting Nucala (Mepolizumab) Covered by Humana in Washington: Complete Forms, Appeals & Support Guide

Answer Box: Fast Track to Nucala Coverage

Nucala (mepolizumab) requires prior authorization for Humana Medicare Advantage plans in Washington. Submit the 2024 Request for Medicare Prescription Drug Coverage Determination Form with eosinophil counts ≥150 cells/μL and evidence of optimized inhaled therapy failure. Use CoverMyMeds for fastest processing (often under 7 days). If denied, appeal within 65 days using Humana's member portal or fax 800-949-2961. Washington residents can request external review through the Office of Insurance Commissioner at 800-562-6900.

Table of Contents

  1. Start Here: Verify Your Plan & Coverage
  2. Required Forms & Documentation
  3. Submission Portals & Electronic Options
  4. Fax & Mail Submission Details
  5. Specialty Pharmacy Coordination
  6. Support Lines & Contact Information
  7. Washington State Appeals & External Review
  8. Common Denial Reasons & Solutions
  9. Costs & Financial Assistance

Start Here: Verify Your Plan & Coverage

Before submitting any paperwork, confirm your specific Humana plan type and Nucala's status on your formulary.

Coverage at a Glance

Requirement Details Documentation Needed Source
Plan Type Medicare Advantage/Part D Member ID card Humana Member Portal
Eosinophil Count ≥150 cells/μL (within 6 weeks) Lab results Clinical evidence required
Age Requirement ≥6 years for severe asthma Medical records FDA labeling
Prior Therapy Optimized inhaled therapy failure Treatment history PA Requirements
Prescriber Asthma/allergy specialist preferred Provider credentials Plan policy
Tip: Check your plan's drug formulary first by logging into your Humana member account and searching for "Nucala" or "mepolizumab" to see its tier status and any restrictions.

Required Forms & Documentation

Primary Form: Coverage Determination Request

Download the current 2024 Request for Medicare Prescription Drug Coverage Determination Form from Humana's forms page. Available in both English and Spanish versions.

Step-by-Step: Fastest Path to Approval

  1. Gather Clinical Evidence (Patient/Clinic)
    • Recent eosinophil count ≥150 cells/μL
    • Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) scores
    • Documentation of exacerbation history
    • Timeline: Same day
  2. Complete PA Form (Prescriber)
    • Use CoverMyMeds portal or download PDF
    • Include "Supporting Information for Exception Request" section
    • Timeline: 1-2 business days
  3. Submit Electronically (Recommended)
    • CoverMyMeds: Real-time tracking available
    • Humana Provider Portal: Direct submission
    • Timeline: 24/7 availability
  4. Monitor Status (Patient/Clinic)
    • Check CoverMyMeds dashboard or call Humana
    • Timeline: Determination typically within 7 days
  5. Follow Up on Approval (Patient)
    • Coordinate with specialty pharmacy if approved
    • Timeline: 1-2 days for pharmacy coordination

Clinician Corner: Medical Necessity Letter Checklist

When completing the PA request, ensure your medical necessity letter includes:

  • Problem Statement: Severe eosinophilic asthma inadequately controlled
  • Prior Treatments: Document specific inhaled therapies tried, doses, duration, and outcomes
  • Clinical Rationale: Reference FDA labeling for Nucala indications
  • Biomarker Evidence: Recent eosinophil counts with lab reference ranges
  • Treatment Goals: Reduction in exacerbations, improved quality of life
  • Monitoring Plan: Periodic eosinophil monitoring and asthma control assessments

Submission Portals & Electronic Options

Login: account.covermymeds.com

  • Select Humana from payer list
  • Search "Nucala" or "mepolizumab"
  • Upload supporting documents directly
  • Real-time status tracking available

Humana Provider Portal

Access: provider.humana.com

  • Register for provider account if needed
  • Navigate to pharmacy resources → prior authorizations
  • Plan-specific forms available
  • Electronic submission with confirmation

Alternative: Phone Submission

Clinical Pharmacy Review: 800-555-2546

  • Hours: Monday-Friday, 8am-8pm ET
  • Request drug-specific forms
  • Can initiate PA over phone with follow-up documentation

Fax & Mail Submission Details

Fax Numbers

Submission Type Fax Number Notes
PA Requests 877-486-2621 Include cover sheet
Specialty Medications 888-447-3430 For high-cost/high-risk drugs
Appeals 800-949-2961 Member appeals only

Mail Address

Clinical Pharmacy Review
Humana Inc.
P.O. Box 14601
Lexington, KY 40512-4601

Note: Electronic submission through CoverMyMeds typically processes faster than fax or mail, often providing determination within 5-7 business days versus 10-14 days for paper submissions.

Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy

Humana partners with CenterWell Specialty Pharmacy for Nucala distribution. Access coordination tools through the provider portal.

Key Steps:

  1. E-prescribe directly to CenterWell upon PA approval
  2. Patient enrollment in specialty pharmacy program
  3. Coordination of delivery and injection training
  4. Ongoing refill management and adherence monitoring

Support Lines & Contact Information

Member Support

Humana Customer Care: 800-457-4708

  • General coverage questions
  • PA status inquiries
  • Appeals assistance

Provider Support

Provider Services: 800-555-2546

  • PA submission assistance
  • Clinical review requests
  • Peer-to-peer review scheduling

Patient Phone Script

"Hi, I'm calling to check the status of a prior authorization request for Nucala, generic name mepolizumab, for [patient name], member ID [number]. The PA was submitted on [date]. Can you tell me the current status and if any additional information is needed?"

Washington State Appeals & External Review

Washington provides strong consumer protections for insurance denials through a comprehensive appeals process.

Internal Appeals Process

Timeline: 65 days from denial notice
Method: Humana member portal, fax 800-949-2961, or mail
Forms: Request for Redetermination form (available in English/Spanish)

External Review (IRO Process)

If internal appeals fail, Washington residents can request Independent Review Organization (IRO) review:

Contact: Washington Office of Insurance Commissioner
Phone: 800-562-6900
Timeline: 180 days from final internal denial to request external review
Process: Submit IRO request form to your insurer, who forwards to OIC-assigned IRO

Washington Advantage: The state's external review process is overseen by medical specialists who can override insurer decisions based on medical necessity, even if the plan's internal definition differs from standard medical practice.

Appeals Playbook for Humana in Washington

Appeal Level Timeline Method Required Forms Contact
Internal (1st) 65 days from denial Online, fax, mail Redetermination request 800-949-2961
Internal (2nd) 60 days from 1st denial Same methods Reconsideration form Same
External (IRO) 180 days from final Submit to insurer IRO request form 800-562-6900
Expedited 72 hours if urgent Phone + follow-up Medical urgency docs 800-867-6601

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Eosinophil count too low Retest within 6 weeks of PA submission Lab results showing ≥150 cells/μL
Step therapy not completed Document prior therapy failures Treatment history with specific drugs, doses, durations
Non-formulary status Request formulary exception Medical necessity letter explaining why alternatives won't work
Off-label dosing Provide clinical justification Literature support, specialist recommendation
Missing specialist requirement Obtain referral or consultation Pulmonologist or allergist evaluation

From Our Advocates

We've seen many Washington patients successfully overturn initial Nucala denials by ensuring their eosinophil counts were drawn within the 6-week window and by having their pulmonologist clearly document why standard inhaled therapies at maximum doses were insufficient. The key is comprehensive documentation of the treatment journey, not just the current clinical picture.

Costs & Financial Assistance

Manufacturer Support

GSK For You Program

  • Copay assistance for eligible patients
  • Patient support services
  • Financial hardship programs
  • Contact: Visit GSK's patient assistance website

Out-of-Pocket Costs

Without PA approval, Nucala's list price is approximately $3,837 per dose. With Humana coverage and PA approval, patient responsibility depends on:

  • Plan formulary tier
  • Deductible status
  • Copay/coinsurance structure

When to Escalate

Contact the Washington Office of Insurance Commissioner if you experience:

  • Delayed responses beyond stated timelines
  • Requests for inappropriate documentation
  • Denial of expedited review for urgent cases
  • Discrimination based on disability or other protected characteristics

OIC Consumer Advocacy: 800-562-6900
Online Complaint Portal: insurance.wa.gov/file-complaint

Counterforce Health: Streamlined Appeals Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to craft targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis—whether PA criteria, step therapy, or "not medically necessary"—and drafts point-by-point responses aligned to the plan's own rules, incorporating FDA labeling, peer-reviewed studies, and specialty guidelines with the required clinical facts and operational details payers expect.

For complex cases involving multiple denials or appeals, Counterforce Health provides payer-specific workflows and produces letters that meet procedural requirements while tracking deadlines and required documentation, helping clinicians save time and patients get the coverage they need.

FAQ

How long does Humana PA take in Washington?
Standard PA decisions typically come within 7-14 business days. Expedited reviews for urgent medical situations can be processed within 72 hours.

What if Nucala is non-formulary on my plan?
Submit a formulary exception request using the same coverage determination form, with additional documentation explaining why formulary alternatives are inappropriate.

Can I request an expedited appeal?
Yes, if your health could be seriously jeopardized by delays. Call 800-867-6601 for expedited processing and follow up with required documentation.

Does step therapy apply if I've tried alternatives outside Washington?
Prior therapy from other states typically counts toward step therapy requirements. Include complete treatment records with your PA submission.

What happens if my appeal is denied?
Washington residents can request external review through an Independent Review Organization (IRO) within 180 days of the final internal denial.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with insurance appeals in Washington, contact the Office of Insurance Commissioner at 800-562-6900.

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