By Counterforce Health Team in Nucala (mepolizumab) —

Resources to Get Nucala (Mepolizumab) Approved with Humana in North Carolina: Complete Forms, Portals & Appeals Guide

Answer Box: Getting Nucala Covered by Humana in North Carolina

Nucala (mepolizumab) requires prior authorization from Humana with documented blood eosinophil count ≥150 cells/μL and severe asthma despite optimized inhaled therapy. Start here: 1) Download the current PA form from Prescriber Point or submit electronically via CoverMyMeds, 2) Gather eosinophil labs, asthma control tests, and treatment history, 3) If denied, you have 65 days to appeal internally and can request external review through Smart NC within 120 days.

Table of Contents

Verify Your Plan & Find Forms

Before starting any prior authorization process, confirm your specific Humana plan type. Medicare Advantage, commercial, and Medicaid plans have different forms and timelines.

Check your member ID card or log into your Humana member portal to verify:

  • Plan name and type (MA, commercial, Medicaid)
  • Formulary tier for Nucala
  • Whether step therapy applies
  • Your specific region's requirements
Note: North Carolina Humana members should verify if their plan is state-regulated (eligible for NC external review) or self-funded employer coverage, as appeal rights differ.

Prior Authorization Forms & Requirements

Current 2024 Forms

Electronic Submission (Recommended): Use CoverMyMeds for fastest processing. Select Humana as the payer and Nucala as the medication to start an electronic PA request.

Paper Forms: Download the most current Humana Nucala PA form from Prescriber Point (provider credentials may be required) or access through the Humana Provider Portal.

Required Clinical Documentation

Your prescriber must include:

  • Blood eosinophil count ≥150 cells/μL within the previous 6 weeks
  • Age verification (≥6 years for asthma indication)
  • Severe asthma documentation with at least 3 months of combination inhaled corticosteroid therapy plus another controller
  • Prescriber specialty (asthma/allergy specialist preferred)
  • ICD-10 codes and treatment history
  • Prior therapy failures or contraindications to alternatives

Submission Portals & Electronic Options

Primary Electronic Channels

CoverMyMeds ePA: The preferred method for electronic prior authorization. Providers can:

  • Submit requests 24/7
  • Track status in real-time
  • Receive automated updates
  • Upload supporting documents directly

Humana Provider Portal: Log in at provider.humana.com to:

  • Access plan-specific PA forms
  • Submit requests electronically
  • Check approval status
  • Download determination letters

Member Portal Options

Humana members can file formulary exception requests online through their member account portal for non-formulary coverage or utilization management overrides.

Fax Numbers & Mailing Addresses

Prior Authorization Submissions

  • General PA Fax: Check your specific form for the current fax number (varies by plan and region)
  • Provider Support: 800-555-CLIN (2546) for clinical pharmacy review assistance

Appeals and Grievances

  • Appeals Fax: 800-949-2961
  • Mail Address:
    • Humana Grievance and Appeal Department
    • P.O. Box 14638
    • Lexington, KY 40512-4638
Tip: Always include a cover sheet with member ID, prescriber information, and "URGENT - NUCALA PRIOR AUTHORIZATION" for faster processing.

Specialty Pharmacy Enrollment

Humana uses CenterWell Specialty Pharmacy (formerly Humana Pharmacy) as its primary specialty pharmacy network for Nucala.

Enrollment Process

  1. New Prescriptions: Physicians can submit to CenterWell via:
    • Fax prescription with PA approval
    • Phone: Contact CenterWell directly
    • E-prescription through EMR system
  2. Transferring Existing Prescriptions:
    • Online: Sign into CenterWell Pharmacy account → "Transfers" tab → Select prescription from claims history
    • Mobile App: Download CenterWell Pharmacy app → "Transfer a prescription" → Photo prescription label

Important Transfer Notes

  • Controlled substances cannot be transferred - require new prescription from prescriber
  • Some medications may not appear if not on your specific plan's drug list
  • CenterWell will coordinate delivery after PA approval and contact you for copay information

Member & Provider Support Lines

Member Services

  • General Customer Service: 1-800-233-4013
  • TTY Users: 711
  • Member ID Card: Check the back for your plan-specific number

Provider Support

  • Clinical Pharmacy Review: 800-555-CLIN (2546), Monday-Friday, 8 AM
  • Provider Services: Available through Humana Provider Portal
  • Expedited Reviews: 800-867-6601 (mainland U.S.)

What to Ask When Calling

  • Request your PA case number for tracking
  • Ask for specific denial reasons if applicable
  • Confirm required documentation
  • Request expedited review if medically urgent
  • Get fax confirmation numbers for submissions

North Carolina Consumer Protection

North Carolina offers robust consumer protections through Smart NC, part of the NC Department of Insurance.

Smart NC External Review

  • Eligibility: State-regulated plans (not self-funded employer plans unless opted in)
  • Timeline: 120 days after final internal appeal denial to request external review
  • Standard Review: Decision within 45 days
  • Expedited Review: Decision within 72 hours for urgent cases
  • Contact: 1-855-408-1212 for free advocacy assistance

How to File External Review

  1. Complete external review request form (available on NCDOI website)
  2. Submit supporting medical records
  3. Smart NC assigns Independent Review Organization (IRO)
  4. IRO decision is binding on Humana
Important: Smart NC can waive the internal appeal requirement for expedited external reviews in urgent situations.

Appeals Playbook

Internal Appeals Timeline

  • Filing Deadline: 65 days from denial notice for Medicare members
  • Standard Review: 7 days for Part D drug appeals
  • Expedited Review: 72 hours when delay could harm health

Step-by-Step Appeal Process

  1. Gather Documentation
    • Original denial letter
    • Additional clinical evidence
    • Prescriber support letter
    • Treatment history
  2. Submit Internal Appeal
    • Use Humana member portal online submission
    • Mail to Humana Grievance and Appeal Department address above
    • Fax to 800-949-2961
  3. If Internal Appeal Denied
    • Request external review through Smart NC within 120 days
    • Submit form and medical records
    • Await IRO decision (binding on Humana)

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all Humana plans PA form with clinical evidence Humana PA Policy
Age Minimum ≥6 years for asthma indication Birth date verification FDA Label
Eosinophil Count ≥150 cells/μL within 6 weeks Lab results Clinical Guidelines
Prescriber Specialty Asthma/allergy specialist preferred Provider credentials Humana Policy
Step Therapy May apply to alternatives first Prior therapy documentation Humana Drug Lists
Appeal Deadline 65 days from denial (Medicare) Denial letter with date CMS Guidelines

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals with the right clinical evidence—from FDA labeling to peer-reviewed studies—saving time and improving approval rates.

FAQ

Q: How long does Humana prior authorization take for Nucala in North Carolina? A: Standard PA reviews take up to 7 days for Part D coverage. Electronic submissions through CoverMyMeds typically process faster than paper forms.

Q: What if Nucala is not on my Humana formulary? A: You can request a formulary exception through your member portal or by calling member services. Your prescriber must provide supporting documentation that covered alternatives would be less effective.

Q: Can I request an expedited appeal if my asthma is severe? A: Yes, if waiting for a standard decision could seriously harm your health, you can request expedited review. Call 800-867-6601 for urgent requests.

Q: Does step therapy apply if I've tried alternatives outside North Carolina? A: Document all prior therapies with your prescriber, including those from other states. Humana should accept this documentation to satisfy step therapy requirements.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by Humana directly. External appeals in North Carolina are reviewed by independent organizations through Smart NC and are binding on Humana.

Q: How do I know if my plan is eligible for North Carolina external review? A: Most individual and small group plans are state-regulated and eligible. Large employer self-funded plans may not be unless they opted into NC's system. Contact Smart NC at 1-855-408-1212 to verify.

Update Cadence: Staying Current

Forms and policies change regularly. Check these resources quarterly or before each new PA submission:

  • Humana Provider Portal: Updated forms and policy changes
  • CoverMyMeds: Current electronic submission requirements
  • Smart NC: Any changes to North Carolina external review procedures
  • Prescriber Point: Most current PA forms by plan and region
From Our Advocates: We've seen cases where using an outdated PA form delayed approval by weeks. One patient's severe asthma required immediate treatment, but their clinic submitted a 2023 form in late 2024. The resubmission with current forms and updated eosinophil counts led to approval within days. Always verify you're using the most current version.

When working with Counterforce Health, our platform automatically uses the most current forms and requirements for your specific Humana plan and North Carolina regulations, reducing delays and improving approval success rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. For specific coverage questions, contact Humana member services directly. North Carolina residents should contact Smart NC for assistance with insurance appeals and external review rights.

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