By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by Blue Cross Blue Shield Florida: Complete Guide with Forms and Appeals

Quick Start: Getting Nucala Covered by Florida Blue

Nucala (mepolizumab) requires prior authorization from Florida Blue Cross Blue Shield for severe eosinophilic asthma (age 6+) or other FDA-approved conditions. Your doctor must submit clinical documentation showing eosinophilic phenotype, failed standard therapies, and symptom improvement expectations. Submit requests through the Florida Blue provider portal or call 1-877-719-2583. If denied, you have 180 days to file an internal appeal, followed by external review through Florida's Department of Financial Services. Start by confirming your plan covers specialty biologics and gathering your eosinophil counts and prior treatment records.

Table of Contents

  1. Verify Your Plan Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Requirements
  5. Prior Authorization Checklist
  6. Common Denial Reasons
  7. Appeals Process in Florida
  8. Support Contacts
  9. Cost-Saving Resources
  10. FAQ

1. Verify Your Plan Coverage

Before starting the prior authorization process, confirm Nucala is covered under your specific Florida Blue plan. Coverage varies by product type (commercial, Medicare Advantage, etc.).

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all outpatient settings Florida Blue PA page Florida Blue
Formulary Status Specialty tier (Tier 5/6) Plan formulary document Plan materials
Age Requirement 6 years or older Medical policy Florida Blue policy
Specialty Pharmacy Accredo or CVS/Caremark only Specialty pharmacy list Florida Blue
Appeal Deadline 180 days from denial Florida insurance law FL DFS
Note: Prior authorization is not required for emergency room, inpatient hospital, or urgent care administrations.

2. Required Forms and Documentation

Primary Forms

For Medical Benefit (Provider-Administered):

For Self-Administered Specialty:

  • Use electronic prior authorization through CoverMyMeds
  • Alternative: Call Prime Therapeutics at 800-424-4947

Required Clinical Documentation

Your prescriber must include:

  • Diagnosis confirmation: Severe eosinophilic asthma with documented eosinophilic phenotype
  • Age verification: Patient must be 6 years or older
  • Prior therapy records: Documentation of optimized inhaled corticosteroids and other standard treatments
  • Eosinophil counts: Recent lab results showing elevated eosinophils
  • Treatment response goals: Expected outcomes (reduced exacerbations, decreased rescue medication use)
  • Compliance assessment: Patient's ability to adhere to injection schedule
Clinician Corner: Include specific eosinophil count values, ACT/ACQ scores if available, and exacerbation history over the past 12 months. Reference FDA labeling for dosing by indication.

3. Submission Portals and Methods

Electronic Submission (Preferred)

Provider Portal Options:

  • Availity.com - Primary Florida Blue provider portal
  • CoverMyMeds - For pharmacy benefit requests
  • New Century Health (my.newcenturyhealth.com) - For oncology/hematology specialty drugs only

Alternative Submission Methods

Fax: 1-904-357-6699 (medical benefit drugs) Phone: 1-877-719-2583 (general prior authorization)

Processing Timeframes

  • Standard review: 72 hours (electronic) or 10 calendar days (fax)
  • Expedited review: 24 hours when urgent criteria are met
  • AI-assisted decisions: 90% of authorizations decided within seconds, but all denials reviewed by clinical specialists

4. Specialty Pharmacy Requirements

Nucala is classified as a Limited Distribution Drug (LDD) and must be obtained through designated specialty pharmacies.

In-Network Specialty Pharmacies

Pharmacy Phone Services
Accredo Health Group 888-425-5970 Self- and provider-administered
CVS/Caremark Specialty 866-278-5108 Self- and provider-administered
Important: Using any other pharmacy will result in out-of-network costs or non-coverage.

Pharmacy Setup Process

  1. Provider sends prescription to Accredo or CVS/Caremark Specialty
  2. Pharmacy contacts patient to coordinate delivery and injection training
  3. Prior authorization must be approved before dispensing
  4. Patient receives medication with injection supplies and instructions

5. Prior Authorization Checklist

Before Submitting

  • Confirm patient has severe eosinophilic asthma diagnosis
  • Verify patient age (6+ years required)
  • Document eosinophil count levels
  • Record prior inhaled therapy trials and outcomes
  • Note any contraindications to alternative biologics
  • Calculate appropriate dosing based on indication
  • Identify preferred specialty pharmacy

Clinical Documentation Checklist

  • Complete medical history and physical exam notes
  • Recent eosinophil count (within 6 months)
  • Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) scores
  • Documentation of exacerbations in past 12 months
  • Prior medication trials with dates and outcomes
  • Current inhaled therapy regimen and compliance
  • Treatment goals and expected monitoring plan

6. Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Eosinophil criteria not met Submit recent lab values showing elevated eosinophils Complete blood count with differential
Insufficient prior therapy Document failed trials of inhaled corticosteroids and other standard treatments Pharmacy records, physician notes
Age requirement Verify patient is 6 years or older Birth certificate, medical records
Off-label dosing Provide clinical justification for dosing variation Medical literature, FDA labeling
Step therapy requirement Request exception based on contraindications or prior failures Medical necessity letter

Medical Necessity Letter Template

When appealing, your physician should address:

  1. Patient's specific diagnosis with ICD-10 codes
  2. Severity of condition and impact on quality of life
  3. Prior treatments tried and reasons for failure/discontinuation
  4. Clinical rationale for Nucala specifically
  5. Expected outcomes and monitoring plan
  6. Supporting literature from FDA labeling or peer-reviewed studies

7. Appeals Process in Florida

If your prior authorization is denied, Florida law provides multiple appeal levels.

Internal Appeal (First Level)

Deadline: 180 days from denial notice Timeline: 30 days for standard review, 6 days for urgent cases How to file:

  • Use forms provided in denial letter
  • Submit via Florida Blue member portal
  • Include additional clinical documentation

Expedited Appeal

When to use: Delay could cause severe pain, deterioration, or functional impairment Timeline: 4 business days maximum Special note: Can be filed simultaneously with standard internal appeal

External Review (Independent)

When available: After internal appeal denial Process: Florida Department of Financial Services coordinates independent medical review Cost: No charge to patient Timeline: Standard cases within 45 days, urgent within 72 hours

Tip: For external review, emphasize medical necessity and include peer-reviewed literature supporting Nucala use for your specific condition.

8. Support Contacts

Florida Blue Member Services

  • Phone: Number on your member ID card
  • Online: FloridaBlue.com member portal
  • What to ask: Prior authorization status, formulary tier, specialty pharmacy requirements

Provider Support

  • Prior authorization: 1-877-719-2583
  • Specialty pharmacy: 1-904-357-3900
  • Clinical review: Request peer-to-peer consultation if denied

Florida State Resources

  • Consumer hotline: 1-877-MY-FL-CFO (1-877-693-5236)
  • Department of Financial Services: Online complaint portal
  • Insurance Consumer Advocate: For systemic coverage issues

When dealing with complex insurance coverage challenges, Counterforce Health helps patients and clinicians navigate prior authorization denials by creating targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each insurer's specific requirements, potentially saving months of back-and-forth communications.

9. Cost-Saving Resources

Manufacturer Support

  • GSK For You Program: Patient assistance for eligible individuals
  • Copay assistance: May reduce out-of-pocket costs for commercially insured patients
  • Information: Visit GSK's patient support website

Foundation Grants

Research disease-specific foundations that may provide financial assistance for biologic medications. Many offer grants based on diagnosis and financial need.

State Programs

Florida residents may qualify for additional assistance through state pharmaceutical programs or Medicaid if eligible.

10. FAQ

How long does Florida Blue prior authorization take? Standard requests are processed within 72 hours electronically or 10 days by fax. Urgent requests receive decisions within 24 hours.

What if Nucala is not on my formulary? Request a formulary exception through the prior authorization process. Include medical necessity documentation and evidence that covered alternatives are inappropriate.

Can I appeal if I miss the 180-day deadline? Generally no, but exceptions may apply if you weren't properly notified of appeal rights. Contact Florida's Department of Financial Services for guidance.

Does step therapy apply to Nucala? Florida Blue may require trials of other asthma biologics first. Request an exception if you have contraindications or have previously failed other treatments.

What's the difference between medical and pharmacy benefit coverage? Provider-administered Nucala typically falls under medical benefit, while self-administered versions may be pharmacy benefit. This affects prior authorization forms and submission processes.

How do I transfer from another specialty pharmacy? Contact Accredo or CVS/Caremark Specialty directly. They can coordinate the transfer and ensure continuity of care.

From Our Advocates: We've seen patients successfully overturn initial Nucala denials by working closely with their pulmonologists to document specific eosinophil trends over time, rather than relying on a single lab value. Comprehensive documentation showing the progression from standard therapy failures to biologic need often strengthens the medical necessity case considerably.

When to Escalate

Contact Florida's Department of Financial Services if:

  • Florida Blue violates appeal timelines
  • You believe the denial contradicts your plan's written policy
  • You need help understanding your appeal rights

File a complaint: MyFloridaCFO.com or call 1-877-693-5236

For complex cases involving multiple denials or policy interpretation issues, platforms like Counterforce Health can help analyze your specific situation and create comprehensive appeals that address each insurer's unique requirements and decision-making criteria.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeal processes. It is not medical advice and does not guarantee coverage approval. Always consult with your healthcare provider about treatment decisions and contact your insurance company directly for plan-specific requirements. Insurance policies and procedures may change; verify current information with official sources.

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