By Counterforce Health Team in Nucala (mepolizumab) —

How Long Does It Take to Get Nucala (Mepolizumab) Approved by Cigna in California? Complete Timeline & Appeals Guide

Quick Answer: Nucala (Mepolizumab) Approval Timeline with Cigna in California

Standard timeline: 2-15 business days from complete submission. Cigna/Express Scripts typically responds within 2 business days for routine requests, up to 15 business days maximum under California law. Expedited reviews: 72 hours for urgent cases.

Fastest path to approval:

  1. Ensure eosinophil count ≥300 cells/μL documented within 6 weeks
  2. Submit complete prior authorization via Cigna provider portal or fax to 1-866-873-8279
  3. Include step therapy documentation and specialist prescription

Start today: Contact your allergist/pulmonologist to gather required labs and treatment history before PA submission.

Table of Contents

What Affects Nucala Approval Timing

Several factors influence how quickly Cigna approves Nucala (mepolizumab) in California:

Benefit Type & Plan Structure

  • Commercial plans through Express Scripts: typically 2-5 business days
  • Medicare Advantage: up to 15 business days under federal guidelines
  • Self-funded employer plans: may vary but follow California regulations

Complexity of Clinical Criteria Nucala requires meeting specific biomarker thresholds. Cigna's 2024 policy mandates:

  • Blood eosinophil count ≥300 cells/μL within prior 6 weeks
  • Age ≥6 years for asthma, ≥18 for EGPA
  • Prescription by allergist, pulmonologist, or immunologist
  • Documentation of severe eosinophilic asthma or active EGPA

Completeness of Documentation Missing information triggers automatic holds. Complete submissions process fastest.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Clinical Requirements:

  • Recent blood eosinophil count (≥300 cells/μL within 6 weeks)
  • Confirmed diagnosis: severe eosinophilic asthma or EGPA
  • Treatment history showing inadequate control with standard therapies
  • Current medication list including corticosteroid use
  • Specialist consultation notes (allergist/pulmonologist/immunologist)

Administrative Items:

  • Patient demographics and Cigna ID number
  • Prescriber NPI and specialty verification
  • Prescription details: dose (100mg for asthma, 300mg for EGPA), frequency (every 28 days)
  • ICD-10 codes: J45.9 (asthma) or M30.1 (EGPA)

Forms & Submission:

Tip: Download the most current forms from Cigna's provider portal, as requirements update periodically.

Submission to Initial Review (1-5 Days)

California Timeline Requirements

Under California law, Cigna must process prior authorizations within specific timeframes:

  • Standard requests: Up to 15 business days maximum
  • Expedited/urgent requests: 72 hours
  • Concurrent review (if therapy expires): 24 hours

Submission Methods

Fastest Options:

  1. Electronic Portal: Cigna provider portal (real-time submission confirmation)
  2. Fax: 1-866-873-8279 for Express Scripts pharmacy authorizations
  3. Phone: Follow up within 24 hours to confirm receipt

What Reviewers Check First

Cigna's initial review focuses on:

  • Eosinophil count meets threshold (≥300 cells/μL)
  • Specialist prescriber credentials
  • Step therapy compliance (previous treatments tried)
  • Age and diagnosis criteria met

Additional Information Requests (1-7 Days)

If Cigna requests additional information, the review clock stops until documentation is provided. Common requests include:

Missing Lab Values

  • Recent complete blood count with differential
  • Historical eosinophil trends if available

Treatment History Clarification

  • Specific medications tried and duration
  • Reasons for discontinuation (ineffectiveness vs. intolerance)
  • Emergency department visits or hospitalizations

Specialist Documentation

  • Consultation notes confirming severe eosinophilic phenotype
  • Assessment of asthma control (ACT/ACQ scores if available)
Note: Respond to information requests within 48 hours to avoid processing delays.

Decision Window & Outcomes

Typical Approval Timeline

Submission Quality Express Scripts Response Cigna Final Decision
Complete documentation 1-2 business days 2-5 business days
Missing minor details 3-5 business days 5-10 business days
Incomplete submission 7-15 business days Up to 15 business days

Reading Your Approval Letter

Approved: Look for:

  • Specific quantity limits (e.g., "3 x 100mg doses per 28 days")
  • Authorization period (typically 6 months initial, 12 months renewal)
  • Specialty pharmacy designation (usually Accredo)

Conditional Approval: May require:

  • Additional monitoring parameters
  • Specific administration site requirements
  • Regular eosinophil count follow-ups

If Denied: California Appeals Process

Internal Appeals with Cigna

Level 1 Appeal:

  • Deadline: 180 days from denial date
  • Timeline: Up to 30 days for standard, 15 days for expedited
  • Submit to: Address on denial letter or via provider portal

Level 2 Appeal:

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision
  • Often includes peer-to-peer review opportunity

California Independent Medical Review (IMR)

After internal appeals, California residents can request binding external review through the Department of Managed Health Care:

Eligibility: Denials based on medical necessity, experimental/investigational determinations Timeline: 45 days for standard, 7 days for expedited Cost: Free to patients Success Rate: Approximately 40-60% of IMRs overturn insurer denials

How to Apply:

  1. Call DMHC Help Center: 1-888-466-2219
  2. Submit online at healthhelp.ca.gov
  3. Include all denial letters, clinical records, and appeal documentation

Renewal Cycles & Timeline

When to Initiate Renewal

Start renewal process 30-45 days before current authorization expires:

  • Asthma: Initial 6 months, then 12-month renewals
  • EGPA: Initial 9 months, then 12-month renewals

Renewal Requirements

Clinical Updates Needed:

  • Current eosinophil count
  • Treatment response documentation
  • Ongoing medical necessity assessment
  • Any changes in concurrent medications

Faster Renewal Factors:

  • Stable clinical status
  • Good treatment adherence
  • No safety concerns
  • Same prescriber and pharmacy

Timeline Visual Summary

Day 0: Submit complete PA
  ↓
Days 1-2: Express Scripts initial review
  ↓
Days 2-5: Cigna medical necessity determination
  ↓
Day 5: Decision (approve/deny/more info needed)
  ↓
If denied → Internal appeal (30 days)
  ↓
If still denied → California IMR (45 days)

Milestone Expectations

Phase Timeline Success Factors
Submission Same day Complete documentation
Initial Review 1-2 days Meet basic criteria
Medical Review 2-5 days Strong clinical justification
Appeal (if needed) 30 days Additional evidence
IMR (if needed) 45 days Independent medical opinion

Time-Saving Tips

Portal Usage Best Practices

  • Use Cigna's electronic provider portal for fastest submission
  • Upload all documents in single submission to avoid delays
  • Check portal daily for status updates or information requests

Bundled Evidence Strategy

Submit comprehensive documentation upfront:

  • Complete treatment timeline with specific dates
  • All relevant lab values in single report
  • Specialist consultation notes with clear medical necessity statement

Direct Specialty Routing

  • Ensure prescriber is listed as allergist, pulmonologist, or immunologist
  • Include NPI and specialty certification in submission
  • Consider having specialist submit PA directly rather than primary care

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Eosinophil count not documented Submit recent CBC with differential Lab report ≤6 weeks old
Step therapy not met Document previous treatments tried Medication history with dates
Non-specialist prescriber Transfer to appropriate specialist Allergist/pulmonologist consultation
Insufficient severity documentation Provide asthma control assessments ACT scores, exacerbation history
Missing diagnosis confirmation Submit diagnostic workup ICD-10 codes, clinical notes

California-Specific Rights & Resources

State Protections

California law provides additional protections for specialty drug access:

  • Step therapy override: Available for clinical contraindications
  • Continuity of care: Up to 12 months when switching plans
  • Timely access: Expedited review for urgent clinical needs

Getting Help

Department of Managed Health Care

  • Help Center: 1-888-466-2219
  • Online complaints: healthhelp.ca.gov
  • IMR applications and guidance

Health Consumer Alliance

  • Free assistance with appeals and complaints
  • Multilingual support available
  • healthconsumer.org

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, helping patients, clinicians, and specialty pharmacies navigate complex prior authorization processes more effectively.

FAQ

How long does Cigna take to approve Nucala in California? Standard timeline is 2-15 business days, with most Express Scripts reviews completed within 2 business days of receiving complete documentation.

What if my eosinophil count is below 300 cells/μL? Cigna's policy requires ≥300 cells/μL within 6 weeks. If your count is lower, discuss with your specialist about retesting or alternative treatments.

Can I request expedited review for Nucala? Yes, if treatment delay could seriously jeopardize your health. Expedited reviews must be completed within 72 hours under California law.

What happens if Cigna denies my appeal? California residents can request Independent Medical Review (IMR) through the Department of Managed Health Care, which provides binding external review at no cost.

Does step therapy apply if I'm already on corticosteroids? For EGPA, current corticosteroid use may satisfy step therapy requirements. For asthma, additional controller medications are typically required first.

How often do I need renewal authorization? Initial authorization is 6 months for asthma (9 months for EGPA), then 12-month renewals with updated clinical documentation.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult your healthcare provider for medical guidance and verify current policy details with Cigna. For assistance with complex appeals, consider working with Counterforce Health or other specialized advocacy services.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.