By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (mepolizumab) Covered by Blue Cross Blue Shield in Washington: Complete PA Guide with Appeal Scripts

Answer Box: Getting Nucala Covered in Washington

Blue Cross Blue Shield plans in Washington require prior authorization for Nucala (mepolizumab) with strict criteria: blood eosinophils ≥150 cells/µL or ≥300 cells/µL in past year, failed high-dose inhaled therapy, and specialist prescription. Most approvals come within 15 business days when documentation is complete. If denied, Washington's external review process through certified IROs offers strong patient protections.

First step today: Verify your exact BCBS plan (Premera, Regence, or other) and check their 2025 formulary to confirm Nucala's tier and requirements.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Plan Details
  3. Gather What You Need for Authorization
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. If You Need More Information
  7. If Your Request is Denied
  8. Renewal and Re-Authorization
  9. Washington-Specific Appeal Rights
  10. FAQ: Common Questions
  11. Printable Checklist

What This Guide Covers

This guide helps Washington patients and their clinicians navigate Blue Cross Blue Shield prior authorization for Nucala (mepolizumab), a specialty biologic used for severe eosinophilic asthma, EGPA, HES, and chronic rhinosinusitis with nasal polyps.

You'll learn exactly what documentation BCBS requires, how to submit clean requests that avoid delays, and what to do if you're denied. We'll also cover Washington's strong external review protections that can overturn insurer denials.

Who this helps: Patients with severe eosinophilic conditions, their caregivers, and healthcare providers dealing with BCBS coverage in Washington state.

Before You Start: Verify Your Plan Details

Identify Your Specific BCBS Plan

Washington has multiple Blue Cross Blue Shield affiliates with different formularies and requirements:

  • Premera Blue Cross (largest commercial carrier)
  • Regence BlueShield
  • LifeWise Health Plan

Action step: Check your insurance card for the exact plan name and member ID. The "Rx Plan" code (like B4, N3, E1) determines which formulary applies to you.

Confirm Nucala's Formulary Status

Most BCBS plans in Washington place Nucala on Tier 4 (Specialty) with these typical requirements:

Requirement What It Means Where to Verify
Prior Authorization (PA) Must be approved before coverage Plan formulary PDF or member portal
Specialty Tier Higher cost-sharing (20-50% coinsurance) Benefits summary
Limited Access (LA) Must use in-network specialty pharmacy Formulary notes
Quantity Limits FDA-approved dosing only Drug list restrictions
Tip: Use your plan's online drug search tool or call member services to confirm current tier and restrictions for Nucala.

Medical vs. Pharmacy Benefit

Nucala can be covered under either benefit depending on administration:

  • Pharmacy benefit: Self-injection at home via specialty pharmacy
  • Medical benefit: Clinic administration (less common)

Verify which applies to avoid submitting to the wrong department and causing delays.

Gather What You Need for Authorization

Clinical Documentation Checklist

Diagnosis and Severity:

  • Confirmed diagnosis with ICD-10 codes
  • Specialist evaluation (pulmonologist, allergist, immunologist)
  • Disease severity documentation (ACT/ACQ scores for asthma, exacerbation history)

Laboratory Evidence:

  • Blood eosinophil counts from past 12 months
  • Recent CBC with differential (within 6 weeks preferred)
  • Target: ≥150 cells/µL recent OR ≥300 cells/µL in past year

Prior Therapy Documentation:

  • High-dose inhaled corticosteroid + LABA for ≥3 months
  • Names, doses, duration, and outcomes of each treatment
  • Documentation of adherence and proper technique
  • Any prior biologic trials (benralizumab, dupilumab, omalizumab)

Exacerbation History:

  • Oral steroid courses in past 12 months (dates, doses)
  • Emergency department visits or hospitalizations
  • Unscheduled clinic visits for asthma

Forms and Submission Materials

Contact your BCBS plan to obtain:

  • Current prior authorization form for Nucala
  • Provider portal access information
  • Specialty pharmacy network list
  • Fax numbers for PA submissions
Note: Forms and requirements can change quarterly. Always verify you have the current version before submitting.

Submit the Prior Authorization Request

Step-by-Step Submission Process

1. Complete the PA Form (Provider)

  • Use plan-specific Nucala PA form
  • Include all required clinical data
  • Attach supporting documentation

2. Submit via Preferred Method

Method Timeline Notes
Provider Portal 15 business days standard Electronic submission preferred
Secure Fax 15 business days standard Get confirmation receipt
Expedited Review 72 hours For urgent cases only

3. Include Complete Documentation

  • Specialist consultation notes
  • Lab results (eosinophil counts)
  • Prior therapy failure documentation
  • Current medication list
  • Treatment plan and monitoring strategy

Medical Necessity Letter Template

Your specialist should include a letter addressing:

"Patient has severe eosinophilic asthma with blood eosinophils of [X] cells/µL, meeting BCBS criteria of ≥150 cells/µL. Despite optimized therapy with high-dose ICS/LABA for [duration], patient has experienced [number] exacerbations requiring systemic steroids in the past 12 months. Nucala is medically necessary to reduce exacerbations and steroid dependence per FDA labeling and GINA guidelines."

Follow-Up and Timeline Expectations

Standard Timelines

  • Standard PA decision: 15 business days
  • Expedited review: 72 hours (urgent cases)
  • Additional information requests: 14 days to respond

When and How to Follow Up

Week 1: Confirm receipt via provider portal or phone Week 2: Check status if no decision received Day 14: Call if approaching deadline

Sample follow-up script:

"I'm calling to check the status of a Nucala prior authorization for [patient name], member ID [number], submitted on [date]. Can you provide the current status and expected decision date?"

Document all calls with reference numbers and representative names.

If You Need More Information

Common Additional Requests

BCBS may request:

  • Additional eosinophil lab values
  • Detailed exacerbation timeline
  • Specialist consultation notes
  • Evidence of step therapy completion

How to Respond Quickly

  • Submit requested information within 14 days
  • Use the same submission method as original request
  • Reference the original PA number
  • Include a cover letter summarizing what's being provided

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Eosinophil count too low Submit historical labs showing ≥300 cells/µL
Insufficient prior therapy Document high-dose ICS + LABA trial with dates/outcomes
Missing specialist evaluation Obtain pulmonology/allergy consultation
Step therapy not met Document trial/failure of preferred biologic

First-Level Internal Appeal

Timeline: File within 180 days of denial Process:

  1. Request denial letter with specific reasons
  2. Address each denial point with evidence
  3. Submit appeal with new documentation
  4. Request peer-to-peer review if available

Appeal letter template:

"I am appealing the denial of Nucala for [patient name] dated [date]. The denial states [specific reason]. However, [patient/medical records show evidence that meets criteria]. Attached documentation demonstrates medical necessity per BCBS policy [reference policy section]."

Renewal and Re-Authorization

When to Reapply

Most BCBS plans approve Nucala for 12 months initially. Start renewal process 60-90 days before expiration.

Documentation for Renewal

  • Treatment response evidence (reduced exacerbations, improved ACT scores)
  • Continued medical necessity
  • Updated eosinophil counts
  • Any dose adjustments or monitoring results
From our advocates: Patients who track their symptoms, exacerbations, and quality of life measures throughout treatment often have smoother renewal processes. Keep a simple log of asthma control scores and steroid use to demonstrate ongoing benefit.

Washington-Specific Appeal Rights

External Review Process

Washington offers strong consumer protections through Independent Review Organizations (IROs) under RCW 48.43.535.

Key Features:

  • Available after internal appeals are exhausted
  • 180 days to file from final internal denial
  • Decision within 30 days (72 hours for expedited)
  • IRO decision is binding on the insurer

How to Access:

  1. Complete internal appeals first
  2. Request external review through Washington Office of Insurance Commissioner
  3. Submit via OIC or directly to your insurer
  4. IRO reviews medical necessity using current standards

Contact Information: Washington Office of Insurance Commissioner Consumer Advocacy: 1-800-562-6900

When External Review Helps

External review is particularly effective for:

  • Specialty medications like Nucala
  • Cases where medical evidence supports coverage
  • Disputes over medical necessity definitions
  • Step therapy requirement challenges

FAQ: Common Questions

Q: How long does BCBS PA take in Washington? A: Standard prior authorization decisions are made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Nucala is non-formulary on my plan? A: Request a formulary exception with documentation that preferred alternatives are inappropriate or have failed. Include specialist justification.

Q: Can I request an expedited appeal? A: Yes, if your health could be seriously jeopardized by delays. Your doctor must document the urgent medical need.

Q: Does step therapy apply if I've used Nucala before? A: Many plans waive step therapy if you've been successfully treated with the medication in the past 365 days.

Q: What specialty pharmacies can fill Nucala in Washington? A: Check your plan's specialty pharmacy network. Common options include specialty divisions of major chains, but verify coverage before transferring prescriptions.

Q: How much will Nucala cost with BCBS coverage? A: As a specialty tier medication, expect 20-50% coinsurance. The manufacturer offers copay assistance programs that may help reduce out-of-pocket costs.

Printable Checklist

Before Submitting PA:

  • Verify exact BCBS plan and formulary tier
  • Obtain current PA form from plan
  • Gather eosinophil labs (≥150 recent or ≥300 historical)
  • Document high-dose ICS + LABA trial
  • List all exacerbations in past 12 months
  • Obtain specialist consultation if needed

During PA Process:

  • Submit via provider portal or secure fax
  • Document submission date and reference number
  • Follow up at 1 week and 2 weeks
  • Respond to information requests within 14 days

If Denied:

  • Request detailed denial letter
  • File internal appeal within 180 days
  • Address each denial reason with evidence
  • Consider external review through Washington OIC

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed, payer-specific strategies. Our platform analyzes denial letters and plan policies to create targeted rebuttals that meet each insurer's specific requirements. Learn more about our prior authorization and appeals support.

When navigating complex prior authorization requirements for specialty medications like Nucala, having expert support can make the difference between approval and denial. Counterforce Health's platform helps healthcare teams streamline the appeals process with automated evidence gathering and payer-specific documentation strategies.

Sources & Further Reading

Disclaimer: This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For assistance with appeals or coverage disputes, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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