By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by Cigna in Illinois: Complete Prior Authorization Guide with Appeals

Answer Box: Getting Nucala (Mepolizumab) Covered by Cigna in Illinois

Fastest path to approval: Submit Cigna's prior authorization form with blood eosinophil count ≥150 cells/μL (recent) or ≥300 cells/μL (past year), proof of current systemic corticosteroid use for 4+ weeks, and prescriber credentials from an allergist, immunologist, or pulmonologist. First step today: Call your prescriber to confirm they have recent eosinophil labs and can document your steroid trial. Illinois deadline: If denied, you have 30 days to request external review through the Illinois Department of Insurance.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Appeals Process in Illinois
  9. Renewal and Re-Authorization
  10. Common Denial Reasons & Solutions
  11. Costs and Patient Support
  12. Frequently Asked Questions

What This Guide Covers

This guide helps Illinois patients and their healthcare providers navigate Cigna's prior authorization process for Nucala (mepolizumab), an injectable biologic medication used to treat severe eosinophilic asthma, EGPA, HES, and chronic rhinosinusitis with nasal polyps.

With a list price around $3,837 per injection, Nucala requires careful documentation to demonstrate medical necessity. However, when properly submitted with complete documentation, many prior authorization requests are approved on the first submission.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create point-by-point rebuttals aligned with payer rules.

Before You Start: Verify Your Coverage

Check Your Plan Type

  1. Commercial Cigna plans: Most require prior authorization through Express Scripts
  2. Medicare Advantage: May have different criteria and formulary placement
  3. Medicaid managed care: Check if your plan is administered by Cigna

Confirm Nucala's Formulary Status

Log into your Cigna member portal or call the number on your insurance card to verify:

  • Formulary tier (typically specialty tier)
  • Whether step therapy applies
  • Your specialty medication copay

Verify In-Network Prescriber

Ensure your prescribing physician is in-network and credentialed as an allergist, immunologist, pulmonologist, or otolaryngologist, as Cigna requires specialist prescribing.

Gather Required Documentation

Essential Lab Results

Blood eosinophil count meeting one of these criteria:

  • ≥150 cells per microliter within the previous 6 weeks, OR
  • ≥300 cells per microliter within the past year

Current Treatment Documentation

  • Systemic corticosteroid use: Documentation showing current use (e.g., prednisone) for minimum 4 weeks
  • Prior therapy records: Failed or inadequate response to optimized inhaled corticosteroids plus additional controller medication

Clinical Documentation

  • Complete diagnosis with ICD-10 codes
  • Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) scores
  • Exacerbation history over past 12 months
  • Contraindications to other treatments
  • Treatment goals and monitoring plan

Submit Your Prior Authorization Request

Submission Methods

Online (Fastest):

Phone: (800) 882-4462 for urgent requests

Fax: (855) 840-1678

Complete Request Packet Checklist

  • Cigna Nucala PA form (verify current version)
  • Prescriber attestation and credentials
  • Recent eosinophil lab results
  • Documentation of systemic steroid use
  • Prior therapy failure records
  • Clinical notes supporting medical necessity
Tip: Submit requests early in the week to avoid weekend delays. Include all required documentation in the initial submission to prevent back-and-forth requests for additional information.

Follow-Up and Tracking

Standard Timeline

  • Standard review: 5 business days
  • Expedited review: 24 hours (if delay would jeopardize health)

What to Track

  1. Reference number: Get confirmation number for your submission
  2. Submission date: Important for appeal deadline calculations
  3. Assigned reviewer: Note if clinical pharmacist or medical director

Sample Follow-Up Script

"Hi, I'm calling to check the status of prior authorization reference number [####] for Nucala submitted on [date]. Can you tell me if a decision has been made or if additional information is needed?"

If You're Asked for More Information

Common Requests

  1. Additional lab values: Vitamin B12, tryptase levels to rule out other causes
  2. Pulmonary function tests: Recent spirometry results
  3. Imaging: Chest X-ray or CT to assess for other conditions
  4. Specialist consultation: Confirmation of specialist evaluation

Medical Necessity Documentation

Your prescriber should include:

  • Specific phenotype confirmation (eosinophilic asthma)
  • Inadequate control despite guideline-directed therapy
  • Patient-specific factors supporting Nucala over alternatives
  • Monitoring plan for treatment response

If Your Request Is Denied

Understanding Denial Codes

Common denial reasons:

  • Insufficient eosinophil count documentation
  • Missing specialist prescriber requirement
  • Inadequate prior therapy documentation
  • Step therapy not completed

Immediate Next Steps

  1. Request peer-to-peer review: Your prescriber can speak directly with Cigna's medical director
  2. File internal appeal: You have 180 days from denial date
  3. Consider expedited appeal: If treatment delay poses health risk

When prior authorization requests are denied, Counterforce Health can help analyze the specific denial reasons and create targeted appeals that address each payer concern with appropriate clinical evidence.

Appeals Process in Illinois

Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial Decision deadline: 15 business days for standard; 24 hours for expedited How to file: Written request to Cigna member services

External Review (Independent)

Eligibility: After completing internal appeal process Critical deadline: 30 days from final adverse determination (shorter than most states) Cost: Free to consumers Authority: Illinois Department of Insurance

Illinois-Specific Resources

  • Illinois Department of Insurance Consumer Helpline: (877) 527-9431
  • Illinois Attorney General Health Care Bureau: (877) 305-5145
  • External Review Application: Available through Illinois DOI website
Illinois Note: The 30-day external review deadline is shorter than the federal 4-month standard. Mark your calendar immediately after receiving a final denial.

Coverage Requirements at a Glance

Requirement Cigna Criteria Where to Find It Source
Age ≥18 years (most indications) Patient chart Cigna Policy
Eosinophil Count ≥150 cells/μL (6 weeks) OR ≥300 cells/μL (1 year) Recent lab results Cigna Policy
Prescriber Allergist, immunologist, pulmonologist, or ENT Provider credentials Cigna Policy
Current Treatment Systemic corticosteroid ≥4 weeks Prescription records Cigna Policy
Initial Approval 6 months PA determination Cigna Policy

Renewal and Re-Authorization

Continuation Criteria

After 6 months: Submit evidence of clinical response

  • Reduced exacerbations
  • Improved asthma control scores
  • Steroid reduction (if applicable)
  • Stable or improved pulmonary function

Approval duration: Up to 1 year for continuation therapy

Documentation for Renewal

  • Treatment response assessment
  • Adherence confirmation
  • Ongoing specialist oversight
  • Updated eosinophil levels

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Eosinophil count not met Submit recent labs Blood eosinophil ≥150 cells/μL within 6 weeks
Non-specialist prescriber Transfer to specialist Allergist/immunologist/pulmonologist credentials
Insufficient prior therapy Document treatment failures Detailed medication history with outcomes
Missing steroid documentation Provide current prescriptions Evidence of ≥4 weeks systemic steroid use

Costs and Patient Support

Manufacturer Support

GSK For You Program: May provide copay assistance for eligible patients

  • Commercial insurance copay reduction
  • Uninsured patient programs
  • Prior authorization support

Illinois-Specific Resources

  • Illinois Medicaid: Covers Nucala for eligible patients meeting criteria
  • 340B programs: Available at federally qualified health centers
  • Patient advocacy organizations: Asthma and Allergy Foundation of America

Frequently Asked Questions

How long does Cigna prior authorization take for Nucala in Illinois? Standard review is 5 business days; expedited review is 24 hours if medically urgent.

What if Nucala isn't on my Cigna formulary? Request a formulary exception with medical necessity documentation. Your prescriber can submit this alongside the PA request.

Can I request an expedited appeal in Illinois? Yes, if treatment delay would significantly increase health risks. Both internal and external expedited reviews are available.

Does step therapy apply to Nucala with Cigna? This varies by plan. Check your specific formulary or contact Cigna to confirm whether you must try other biologics first.

What happens if my external review is approved? Cigna must provide coverage. The external review decision is binding on the insurance company.

How do I get help with my appeal in Illinois? Contact the Illinois Department of Insurance at (877) 527-9431 or the Illinois Attorney General's Health Care Bureau at (877) 305-5145.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan, medical history, and clinical circumstances. Always consult your healthcare provider for medical decisions and verify current coverage requirements with your insurance company. For personalized assistance with complex appeals, consider consulting with Counterforce Health or other patient advocacy services.

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