By Counterforce Health Team in Nucala (mepolizumab) —

How to Get Nucala (Mepolizumab) Covered by UnitedHealthcare in Washington: State Appeals Guide with Forms and Timelines

Answer Box: Getting Nucala Covered in Washington

Washington residents have strong protections when UnitedHealthcare denies Nucala (mepolizumab) for severe eosinophilic asthma. State law requires step therapy exceptions within 72 hours if prior biologics failed or are contraindicated. After internal appeals, you can request binding external review through an Independent Review Organization (IRO) within 120 days. Start today: Call UnitedHealthcare at 1-888-838-2342 to request prior authorization, citing Washington's step therapy override law (HB 1879) if applicable. If denied, contact the Washington Office of Insurance Commissioner at 800-562-6900 for appeal assistance.

Table of Contents

  1. Why Washington State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. Washington's Step Therapy Override Protections
  4. Appeals Timeline and Process
  5. External Review Through IRO
  6. Practical Scripts and Documentation
  7. When to Contact State Regulators
  8. Costs and Patient Support
  9. FAQ

Why Washington State Rules Matter

Washington has some of the strongest consumer protections in the nation for specialty drug coverage. Unlike many states, Washington requires insurers to provide clear, accessible processes for step therapy exceptions and mandates specific timelines for prior authorization decisions.

Key Washington Advantages:

  • 72-hour step therapy override decisions (24 hours for urgent cases)
  • Independent external review with medical specialists
  • Binding IRO decisions that insurers must honor
  • Active state oversight through the Office of Insurance Commissioner

These protections apply to fully-insured UnitedHealthcare plans purchased in Washington, including marketplace (ACA) plans and some employer plans. Self-funded employer plans follow federal ERISA rules but may voluntarily adopt Washington's processes.

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare requires prior authorization for Nucala through OptumRx. The typical criteria include:

Coverage Requirements Table

Requirement Details Documentation Needed
Diagnosis Severe eosinophilic asthma (ICD-10 J45.5xx) Medical records, specialist confirmation
Lab Values Blood eosinophils ≥150-300 cells/μL Recent lab results (within 30 days)
Exacerbations ≥2 oral steroid courses or hospitalizations in past year Pharmacy records, hospital records
Step Therapy Trial/failure of preferred biologics (benralizumab, dupilumab) Pharmacy claims, prescriber notes
Age ≥6 years for eosinophilic asthma indication Birth date verification

Submission Process

  1. Access the form: Log into the UnitedHealthcare provider portal or call OptumRx at 1-866-633-2446
  2. Submit documentation: Include prescriber letter, labs, and prior therapy records
  3. Use specialty pharmacy: Optum Specialty Pharmacy required post-approval (1-855-427-4682)
  4. Timeline: Standard decisions within 3-5 business days; urgent requests within 72 hours
Tip: UnitedHealthcare's PreCheck MyRx system covers over 45 drugs as of January 2026, potentially providing same-day approvals for eligible medications.

Washington's Step Therapy Override Protections

Washington's HB 1879 requires insurers to grant step therapy exceptions when clinically justified. This is particularly valuable for Nucala, as UnitedHealthcare typically requires trials of other biologics first.

Exception Criteria

Insurers must approve overrides when your provider documents:

  • Contraindication: The required step drug poses risks (e.g., infection concerns with other biologics)
  • Ineffectiveness: Prior therapy didn't control eosinophils or asthma symptoms
  • Previous failure: You've tried and failed the required drug with documented intolerance or inadequate response
  • Current stability: You're already stable on Nucala from a previous approval

Documentation Requirements

Your provider should submit:

  • Clinical rationale with specific medical reasons
  • Lab results showing eosinophil levels and response to prior treatments
  • Trial records with dates, doses, duration, and outcomes
  • Contraindication evidence such as adverse events or comorbidities

Timeline: 72 hours for standard requests, 24 hours for urgent cases where delays could worsen your condition.

Appeals Timeline and Process

If UnitedHealthcare denies your initial request, Washington provides multiple appeal levels with strict timelines.

Internal Appeals

First Level Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard, 72 hours for urgent
  • How to file: Online portal, phone (1-800-842-2656), or written request

Second Level Appeal:

  • Deadline: 60 days from first-level denial
  • Timeline: 30 days for standard, 72 hours for urgent
  • Enhancement: Submit new clinical evidence or specialist letters
Note: Medicare Advantage plans follow Medicare's appeal timeline, which may differ slightly from commercial plans.

Required Documentation for Appeals

  • Original denial letter with reason codes
  • Updated medical records showing continued need
  • Peer-reviewed studies supporting Nucala for your specific phenotype
  • Specialist consultation if not already provided
  • FDA labeling highlighting approved indications

External Review Through IRO

Washington's Independent Review Organization process provides your strongest protection when internal appeals fail.

Eligibility and Process

Under RCW 48.43.535, you can request external review after:

  • Final internal denial
  • UnitedHealthcare exceeds internal timeline without good cause
  • 120 days from the final internal denial notice

IRO Timeline

Review Type Decision Timeline
Standard ≤20 days from IRO receipt
Expedited ≤72 hours for urgent medical needs

How to Request

  1. Submit written request to UnitedHealthcare within 120 days
  2. Include new evidence such as updated clinical data
  3. IRO assignment: UnitedHealthcare assigns an independent medical reviewer
  4. Binding decision: If overturned, coverage must proceed without patient cost

The IRO decision is legally binding on UnitedHealthcare and cannot be appealed further by the insurer.

Practical Scripts and Documentation

Patient Phone Script for UnitedHealthcare

"I'm calling about prior authorization for Nucala for severe eosinophilic asthma. My doctor says I need a step therapy override under Washington state law HB 1879 because [benralizumab/dupilumab] was ineffective/contraindicated. I have documentation of my eosinophil levels and prior treatment failures. Can you expedite this as an urgent request since delays could worsen my condition?"

Medical Necessity Letter Checklist

Your provider should include:

  • Diagnosis: Severe eosinophilic asthma with ICD-10 code
  • Biomarkers: Current eosinophil count and trends
  • Prior therapies: Specific drugs tried, durations, and outcomes
  • Clinical rationale: Why Nucala is medically necessary now
  • Monitoring plan: How response will be assessed
  • Guidelines: Reference to GINA guidelines or specialty society recommendations

Counterforce Health helps patients and providers create evidence-backed appeals by analyzing denial letters and matching them with appropriate clinical evidence and payer-specific requirements.

When to Contact State Regulators

The Washington Office of Insurance Commissioner provides robust consumer advocacy for denied specialty drugs.

Contact Information

When to Escalate

Contact the OIC when:

  • UnitedHealthcare exceeds appeal timelines
  • Denials appear unreasonable despite strong clinical evidence
  • You need help navigating the external review process
  • You suspect violations of Washington's Insurance Fair Conduct Act

The OIC investigates complaints, contacts insurers for responses, and can impose fines for violations.

Costs and Patient Support

Manufacturer Support

GSK offers patient assistance through:

  • GSK For You program: Copay assistance and patient support
  • Income-based programs: For uninsured or underinsured patients
  • Bridge programs: Coverage during appeals

List Price Context

Nucala's list price is approximately $3,837 per monthly dose, making coverage crucial for most patients. With insurance, copays typically range from $5-50 for commercial plans, higher for Medicare.

State Programs

Washington's Apple Health (Medicaid expansion) covers Nucala with prior authorization. The state's robust Medicaid program provides additional appeal rights through fair hearings.

Continuity of Care Protections

Washington requires insurers to provide continuity of care when:

  • Plan changes: During open enrollment or job transitions
  • Formulary updates: When previously covered drugs are removed
  • Provider networks: When specialists leave the network

These protections typically provide 90-day grace periods for ongoing specialty therapies like Nucala, giving you time to complete prior authorization for new coverage.

From our advocates: We've seen many Washington patients successfully overturn initial Nucala denials by combining strong clinical documentation with the state's step therapy override process. The key is often demonstrating that preferred alternatives were genuinely tried and failed, not just contraindicated on paper. This composite experience highlights how Washington's consumer-friendly laws can make the difference when paired with thorough documentation.

FAQ

How long does UnitedHealthcare prior authorization take in Washington? Standard requests: 3-5 business days. Urgent requests: 72 hours. Washington law requires decisions within these timelines.

What if Nucala is non-formulary on my plan? Request a formulary exception alongside prior authorization. Washington's step therapy laws still apply to non-formulary drugs when medically necessary.

Can I request an expedited appeal if my asthma is worsening? Yes. Call UnitedHealthcare immediately and request urgent/expedited review. Provide documentation of worsening symptoms or risk of hospitalization.

Does step therapy apply if I failed biologics in another state? Yes, documented failures from other states count toward Washington's step therapy requirements. Ensure your provider includes complete pharmacy and medical records.

What happens if the IRO denies my external review? IRO decisions are final for the insurance appeal process. You may still contact the OIC for guidance or consult an attorney about potential legal action under Washington's Insurance Fair Conduct Act.

How do I know if my plan is subject to Washington state laws? Fully-insured plans purchased in Washington (including marketplace plans) follow state laws. Self-funded employer plans may not, but check your plan documents or call member services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently, and individual circumstances vary. Always verify current requirements with your insurer and consult healthcare providers for medical decisions. For personalized assistance with complex appeals, consider working with patient advocacy organizations like Counterforce Health, which specializes in turning insurance denials into successful, evidence-based appeals.

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