By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by Cigna in New York: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Nucala (Mepolizumab) Covered by Cigna in New York

Eligibility: Nucala requires prior authorization from Cigna for severe eosinophilic asthma (ages 6+) with blood eosinophils ≥150 cells/µL and inadequate control despite high-dose inhaled corticosteroids plus controllers. Fastest path: Submit complete PA request via Cigna provider portal with recent eosinophil count, therapy history, and clinical notes. First step today: Call Cigna at the number on your insurance card to verify formulary tier and confirm PA requirements. If denied, New York offers external appeals through the Department of Financial Services within 4 months.

Table of Contents

  1. What This Guide Covers
  2. Before You Start
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Tracking
  6. Understanding Timelines
  7. When Asked for Additional Information
  8. If Your Request is Denied
  9. New York External Appeal Process
  10. Renewal and Re-Authorization
  11. Cost-Saving Options
  12. FAQ

What This Guide Covers

This comprehensive guide helps patients and clinicians navigate Cigna's prior authorization process for Nucala (mepolizumab) in New York State. Whether you're dealing with severe eosinophilic asthma, EGPA, or other approved indications, you'll find the specific forms, documentation requirements, and appeal strategies needed to secure coverage.

Nucala, manufactured by GSK, costs approximately $3,837 per monthly dose according to GSK's pricing information. Given this substantial cost, proper preparation of your prior authorization request is crucial for approval.

Before You Start

Verify Your Plan Type and Coverage

First, confirm your specific Cigna plan details:

  • Commercial vs. Medicare: Requirements differ between plan types
  • Formulary tier: Nucala is typically a Tier 5 specialty medication
  • Pharmacy vs. medical benefit: Most Nucala administration falls under medical benefits

Call the member services number on your insurance card to verify:

  • Whether prior authorization is required
  • Your plan's specific formulary tier for Nucala
  • Any step therapy requirements
  • Your specialty pharmacy network

Check In-Network Status

Ensure your prescribing physician and administration site are in-network with your Cigna plan. Out-of-network providers can complicate the approval process and increase your costs.

Gather Required Documentation

Clinical Requirements Checklist

For Severe Eosinophilic Asthma:

  • Patient age 6 years or older
  • Blood eosinophil count ≥150 cells/µL (within 4 weeks or before any monoclonal antibody therapy)
  • Documented severe eosinophilic asthma diagnosis with ICD-10 code
  • Evidence of inadequate control despite medium-to-high dose inhaled corticosteroids
  • At least one additional controller medication (LABA, LAMA, leukotriene modifier)
  • Complete list of prior therapies with drug names, doses, duration, and reason for discontinuation

For EGPA:

  • Patient age 18 years or older
  • Confirmed EGPA diagnosis
  • Blood eosinophil count ≥1,000 cells/µL before monoclonal antibody therapy
  • Ongoing systemic corticosteroid therapy (minimum 4 weeks)
  • No secondary cause of eosinophilia documented

Documentation to Collect

  1. Lab Results: Recent complete blood count with differential showing eosinophil levels
  2. Clinical Notes: Provider documentation of diagnosis, symptom control, and treatment history
  3. Prescription History: Pharmacy records showing previous medications tried and failed
  4. Imaging/Pulmonary Function: If available and relevant to diagnosis
  5. Insurance Information: Current member ID, group number, and plan details

Submit Your Prior Authorization Request

Cigna/Express Scripts PA Process

Cigna typically manages specialty drugs through Express Scripts. Submit your completed prior authorization request by:

Fax: 1-855-712-6329
Mail: Express Scripts Clinical Services
6985 Financial Drive, Suite 300
Mississauga, ON L5N 0G3

Note: Verify current submission details with Cigna, as addresses may change.

PA Form Requirements

The Cigna prior authorization form requires:

  1. Patient Demographics: Complete insurance and contact information
  2. Prescriber Information: NPI, DEA, practice details
  3. Clinical Justification: Detailed medical necessity explanation
  4. Laboratory Values: Specific eosinophil counts with dates
  5. Treatment History: All previous therapies with outcomes

Clean Request Packet Checklist

  • Completed PA form with all sections filled
  • Provider cover letter explaining medical necessity
  • Recent lab results (eosinophil count)
  • Clinical notes supporting diagnosis and severity
  • Prescription history documentation
  • Any relevant imaging or pulmonary function tests

Follow-Up and Tracking

When to Call Cigna

  • Day 3-5: Confirm receipt of your PA request
  • Day 10-12: Check on processing status
  • Day 20+: Request status update if no decision received

Sample Call Script

"Hi, I'm calling to check on the status of a prior authorization request for Nucala (mepolizumab) for [patient name], member ID [number], submitted on [date]. Can you provide the current status and expected decision timeline? Also, is there a reference number I should use for future calls?"

Document: Reference numbers, representative names, and any additional requirements mentioned.

Understanding Timelines

New York State Requirements

New York insurance law requires health plans to make prior authorization decisions within specific timeframes:

  • Standard requests: 15 calendar days for commercial plans
  • Urgent requests: 72 hours when health could be seriously jeopardized
  • Medicaid managed care: 14 calendar days standard, 72 hours urgent

What Speeds vs. Slows Decisions

Speeds approval:

  • Complete documentation on first submission
  • Clear clinical rationale aligned with Cigna's criteria
  • Recent lab values and therapy history
  • Provider attestation of medical necessity

Slows approval:

  • Missing or incomplete forms
  • Unclear clinical justification
  • Outdated lab values
  • Lack of documented prior therapy failures

When Asked for Additional Information

If Cigna requests more information, respond promptly with:

Medical Necessity Documentation

Include evidence supporting:

  • Clinical severity: Exacerbation history, hospitalizations, oral steroid dependence
  • Eosinophilic phenotype: Lab confirmation of elevated eosinophils
  • Treatment failures: Specific medications tried with doses, duration, and outcomes
  • Guideline support: References to GINA guidelines or specialty society recommendations

Literature Support

Consider including:

  • FDA prescribing information for Nucala
  • Peer-reviewed studies supporting use in your patient's specific condition
  • Clinical practice guidelines from relevant medical societies
  • Drug compendia entries for approved indications

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Eosinophil count too low Provide recent lab with count ≥150 cells/µL or historical high values
Insufficient prior therapy Document specific medications, doses, duration, and failure reasons
Not meeting step therapy Request step therapy exception with clinical justification
Off-label use Provide literature support or switch to FDA-approved indication

First-Level Appeal Process

Submit appeals to: Cigna Healthcare Inc. National Appeals Unit
PO Box 188011
Chattanooga, TN 37422

Timeline: Must appeal within 180 calendar days of denial notice

Peer-to-Peer Review

Request a peer-to-peer discussion with Cigna's medical director by:

  1. Calling the number on your denial letter
  2. Requesting immediate peer-to-peer review
  3. Preparing clinical rationale and supporting literature
  4. Documenting the conversation outcome

New York External Appeal Process

If Cigna upholds their denial after internal appeals, New York residents have strong external appeal rights through the Department of Financial Services.

Filing Requirements

Timeline for External Review

  • Standard: 30 days for decision
  • Expedited: 72 hours with physician attestation of urgent need
  • Drug-specific urgent: 24 hours for urgent drug denials

Submitting Your External Appeal

Contact: 1-800-400-8882 or [email protected]
Documentation: Include all new medical information not previously submitted
Representation: You may appoint a representative to file on your behalf

From our advocates: We've seen many New York external appeals succeed when patients include recent medical literature and clear documentation of treatment failures. The key is presenting new evidence that wasn't available during the internal appeal process.

Renewal and Re-Authorization

When to Re-Apply

Cigna typically approves Nucala for 9-month periods initially. Calendar renewal requests for:

  • 2 months before expiration: Start gathering updated documentation
  • 1 month before expiration: Submit renewal PA request

Renewal Documentation

Include:

  • Updated eosinophil counts
  • Clinical response assessment (symptom control, exacerbation reduction)
  • Any changes in concurrent medications
  • Provider attestation of ongoing medical necessity
  • Documentation of treatment adherence

Cost-Saving Options

Manufacturer Support

GSK For You Program: Offers copay assistance for eligible commercially insured patients. Visit GSK For You or call 1-844-825-8343.

Patient Assistance Programs

  • GSK Patient Assistance Program: For uninsured or underinsured patients
  • Foundation support: Organizations like the Patient Access Network Foundation may provide grants
  • State programs: New York residents may qualify for additional assistance through state pharmaceutical programs

FAQ

How long does Cigna prior authorization take for Nucala in New York?
Standard PA decisions are required within 15 calendar days for commercial plans. Urgent requests must be decided within 72 hours.

What if Nucala is non-formulary on my Cigna plan?
Request a formulary exception by demonstrating medical necessity and providing clinical justification for why preferred alternatives aren't appropriate.

Can I request an expedited appeal if my Nucala is denied?
Yes, if your physician certifies that delay would seriously jeopardize your health. New York allows expedited external appeals with 72-hour decisions.

Does step therapy apply if I've tried similar medications outside New York?
Yes, document all prior therapies regardless of where they were tried. Cigna accepts therapy history from any licensed provider.

What happens if I miss the appeal deadline?
New York's 4-month external appeal deadline is strict and cannot be extended. However, you may still file complaints with state regulators about plan compliance.

How much does Nucala cost without insurance?
GSK lists approximately $3,837 per monthly dose, making prior authorization crucial for affordability.

Can my doctor handle the PA process for me?
Yes, most providers can submit PA requests on your behalf. However, you should stay involved to track progress and provide any additional patient information needed.

What if my Cigna plan changes during treatment?
Contact your new plan immediately to transfer prior authorization. Don't assume approval will automatically continue with plan changes.

Getting Nucala covered by Cigna requires careful attention to documentation and deadlines, but New York's strong consumer protection laws provide multiple appeal avenues if initially denied. The key is thorough preparation and persistence through the process.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and craft compelling appeals that align with each payer's specific criteria.

For additional support with insurance appeals and coverage issues, New York residents can contact Community Health Advocates at 888-614-5400 for free assistance with insurance denials and appeals.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current requirements and personalized guidance. Coverage policies may change, and individual circumstances vary.

Sources & Further Reading

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