By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by Cigna in Ohio: Complete Prior Authorization, Appeals, and Cost Guide

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

Nucala requires prior authorization from Cigna/Express Scripts for severe eosinophilic asthma, typically covered on specialty tier with 6-month initial approval. Key requirements: prescribed by specialist, blood eosinophils ≥150-300 cells/μL, failed high-dose ICS + LABA therapy ≥3 months. First step today: Have your allergist/pulmonologist submit PA via Cigna provider portal with recent eosinophil labs and prior therapy documentation. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance after exhausting internal appeals.

Table of Contents

Understanding Nucala Coverage Basics

Nucala (mepolizumab) is GSK's anti-IL-5 monoclonal antibody for severe eosinophilic asthma, administered as a 100mg subcutaneous injection every 4 weeks. With a list price of approximately $3,837 per dose, understanding your Cigna coverage is crucial for managing costs.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Cigna PA Policy IP0422 Cigna
Formulary Tier Specialty tier (varies by plan) myCigna.com drug list Cigna Member Portal
Step Therapy Must fail high-dose ICS + LABA + LAMA PA policy requirements Cigna Policy
Specialist Required Allergist, pulmonologist, immunologist Coverage criteria Cigna Policy
Age Requirement ≥6 years for asthma FDA indication Cigna Policy
Eosinophil Threshold ≥150-300 cells/μL depending on steroid use Lab requirements Cigna Policy

What Drives Your Out-of-Pocket Costs

Your Nucala costs depend on several benefit design factors that Cigna uses to manage specialty drug expenses:

Formulary Tiering: Nucala typically sits on Cigna's specialty tier, which often requires 20-40% coinsurance rather than flat copays. A $3,837 dose at 30% coinsurance equals $1,151 out-of-pocket per month.

Deductible Application: Many plans apply specialty drugs to the medical (not pharmacy) deductible, meaning you pay full price until reaching your annual deductible limit.

Site of Care: Cigna may require the "least intensive setting" - home administration versus physician office or infusion center - which can affect both coverage and costs.

Note: Ohio's insurance market includes both fully-insured plans (subject to state regulation) and self-funded employer plans (governed by federal ERISA law). Your appeal rights differ depending on your plan type.

Investigating Your Benefits

Before starting the PA process, gather specific information about your Cigna coverage:

Call Cigna Customer Service (number on your ID card) and ask:

  • "Is Nucala on my plan's formulary, and what tier?"
  • "What's my specialty drug coinsurance percentage?"
  • "Does my plan have a separate specialty deductible?"
  • "Is prior authorization required, and who handles it - Cigna or Express Scripts?"
  • "Are there quantity limits or step therapy requirements?"

Document everything: Representative name, reference number, date, and exact answers. This information becomes crucial if you face denials or appeals.

Check Your Member Portal: Log into myCigna.com to verify your current deductible status and download your plan's formulary document.

Financial Assistance Options

Several programs can significantly reduce your Nucala costs, but eligibility varies by insurance type:

Manufacturer Support (Commercial Insurance Only)

GSK Gateway to NUCALA coordinates all assistance programs. Call 844-4-NUCALA (844-468-2252) Monday-Friday, 8 AM-8 PM ET.

Important: Medicare, Medicaid, and other government insurance beneficiaries are ineligible for manufacturer copay assistance.

Independent Foundation Grants

PAN Foundation Asthma Fund provides up to $3,000 annually in copay assistance for eligible patients with commercial insurance and financial need.

Requesting Formulary Exceptions

If Nucala faces coverage barriers, Cigna offers several exception pathways:

Step Therapy Override

When to Request: If you've previously failed required step therapy drugs (high-dose ICS + LABA combinations) or they're medically contraindicated.

Documentation Required:

  • Physician certification that formulary alternatives were tried and ineffective or harmful
  • Clinical notes documenting specific failures or contraindications
  • Timeline of prior therapies with dates and outcomes

Non-Formulary Exception

Process: Physician submits written request via Cigna's formulary exception process with clinical justification for Nucala over covered alternatives.

Timeline: Standard review within 72 hours; expedited within 24 hours if delay would jeopardize health.

Tip: Submit exception requests early in the week to avoid weekend processing delays.

Specialty Pharmacy Coordination

Cigna directs Nucala to Accredo Specialty Pharmacy as their nationally preferred provider, rather than retail pharmacies.

Accredo Benefits:

  • Coordinates PA approval and benefit verification
  • Provides injection training and administration support
  • Offers home delivery and auto-refill programs
  • Handles copay assistance program enrollment

Ordering Process:

  1. Prescriber e-prescribes to Accredo (NCPDP 4436920) or faxes to 888-302-1028
  2. Accredo contacts patient within 24-48 hours of PA approval
  3. Delivery scheduled to home or physician office based on preference

Counterforce Health helps patients navigate complex specialty pharmacy requirements and can assist with coordinating between your physician, Cigna, and Accredo to ensure smooth approval and dispensing processes. Our platform identifies common coordination issues that delay therapy starts and provides targeted solutions.

Appeals Process in Ohio

Ohio provides strong consumer protections for insurance denials, with specific rights that differ from other states:

Internal Appeals (Required First Step)

Timeline: 30 days from denial notice to file Levels: Two internal review levels available Submission: Written request to address on denial letter

External Review (Ohio-Specific Rights)

Eligibility: Available after completing internal appeals for medical necessity denials Timeline: 180 days from final internal denial to request Process: Submit request to your insurer, who notifies the Ohio Department of Insurance Decision Timeline: 30 days standard, 72 hours expedited Binding: IRO decision is final and binding on Cigna

Ohio Advantage: Even if Cigna claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Ohio Department of Insurance Consumer Hotline: 1-800-686-1526

Step-by-Step Appeals Process

  1. File Internal Appeal: Submit written request within 30 days with additional clinical documentation
  2. Await Decision: Cigna has specific timeframes for response (verify current requirements)
  3. Request External Review: If denied, submit external review request within 180 days
  4. IRO Assignment: Ohio DOI assigns Independent Review Organization
  5. Submit Additional Evidence: You can provide supplemental clinical information to the IRO
  6. Final Decision: IRO ruling is binding on Cigna

Annual Renewal Planning

Nucala coverage can change during your plan's annual renewal period. Plan ahead to avoid therapy interruptions:

October-November: Review next year's formulary for any Nucala changes December: If changes affect coverage, request formulary exceptions before January 1 January: Verify PA renewal requirements and submit early if needed

Budget Planning: Track your annual out-of-pocket spending to understand when you'll reach deductible or out-of-pocket maximums.

Conversation Scripts

Calling Cigna for Benefit Verification

"Hi, I'm calling to verify coverage for Nucala, spelled N-U-C-A-L-A, for severe eosinophilic asthma. Can you tell me:

  • Is this drug on my formulary and what tier?
  • What's my specialty drug coinsurance?
  • Is prior authorization required?
  • Are there step therapy requirements I need to complete first?"

Requesting Expedited Review

"My physician has determined that a delay in starting Nucala would seriously jeopardize my health due to severe eosinophilic asthma with frequent exacerbations. I'm requesting an expedited prior authorization review under Cigna's urgent care provisions."

Peer-to-Peer Request Script (for Physicians)

"I'm requesting a peer-to-peer review for my patient's Nucala prior authorization denial. The patient has severe eosinophilic asthma with blood eosinophils persistently above 300 cells/μL and has failed maximum-dose ICS plus LABA therapy with continued exacerbations requiring systemic steroids."

Common Questions

How long does Cigna PA take for Nucala in Ohio? Standard review: 5 business days. Expedited: 72 hours if health would be jeopardized by delay. Submit early in the week for fastest processing.

What if Nucala isn't on my Cigna formulary? Request a formulary exception with clinical documentation showing medical necessity and failure/contraindication of covered alternatives. Ohio residents can appeal denials through external review.

Can I get expedited appeals in Ohio? Yes, both Cigna internal appeals and Ohio external reviews offer expedited timelines (typically 72 hours) when delays would seriously jeopardize your health.

Does step therapy apply if I failed required drugs in another state? Yes, prior therapy failures from any location count toward step therapy requirements. Provide documentation from your previous physicians.

What happens if I lose my job and Cigna coverage? Contact GSK Gateway to NUCALA immediately at 844-4-NUCALA to explore Patient Assistance Program options or bridge coverage during insurance transitions.

How do I find out if my plan is self-funded vs. fully-insured? Ask your HR department or call Cigna. Self-funded plans follow federal ERISA appeals rules rather than Ohio state external review processes.

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting targeted, evidence-backed responses. Our platform helps patients and physicians navigate complex prior authorization requirements and appeal processes, significantly improving approval rates for critical medications like Nucala.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For personalized assistance with Nucala coverage issues, visit www.counterforcehealth.org.

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