By Counterforce Health Team in Nucala (mepolizumab) —

The Requirements Checklist to Get Nucala (Mepolizumab) Covered by Aetna (CVS Health) in Pennsylvania

Answer Box: Getting Nucala (Mepolizumab) Covered by Aetna (CVS Health) in Pennsylvania

Quick Path to Approval: Nucala requires prior authorization from Aetna CVS Health in Pennsylvania. You'll need a specialist (allergist/immunologist or pulmonologist), documented blood eosinophil count ≥150 cells/µL, and proof of failed high-dose inhaled corticosteroids plus additional controllers. Submit the Aetna precertification form with clinical documentation. If denied, Pennsylvania's new external review program has a 50% overturn rate.

First step today: Contact your specialist to confirm your eosinophil count and treatment history meet Aetna's criteria before starting the prior authorization process.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking Your Request
  9. Denial Prevention Tips
  10. Pennsylvania Appeal Process
  11. Printable Checklist

Who Should Use This Checklist

This guide is for Pennsylvania residents with Aetna (CVS Health) insurance who need Nucala (mepolizumab) for:

  • Severe eosinophilic asthma (age 6+)
  • Eosinophilic granulomatosis with polyangiitis (EGPA)
  • Hypereosinophilic syndrome (HES)
  • Chronic rhinosinusitis with nasal polyps (CRSwNP)

Expected outcome: Following this checklist increases your approval chances significantly. Aetna's clinical policy has specific criteria that, when met with proper documentation, typically result in approval.

Member & Plan Basics

✅ Coverage Verification

  • Active Aetna coverage confirmed (call member services number on your insurance card)
  • Plan type identified (commercial, Medicare Advantage, or Medicaid)
  • Specialty pharmacy benefit confirmed (most Nucala requires CVS Specialty Pharmacy)

✅ Financial Requirements

  • Deductible status checked (high-deductible plans may require meeting deductible first)
  • Prior authorization requirement confirmed (required for all Aetna plans)
  • Copay/coinsurance understood (typically 20-40% for specialty tier)
Tip: Nucala's list price is approximately $3,837 per dose. Check if you qualify for GSK's patient assistance program to reduce out-of-pocket costs.

Clinical Criteria Requirements

✅ Severe Eosinophilic Asthma (Most Common Indication)

Age & Diagnosis:

  • Patient age ≥6 years
  • Documented severe eosinophilic asthma diagnosis with ICD-10 code J45.9

Laboratory Requirements:

  • Baseline blood eosinophil count ≥150 cells/µL (recent lab results required)
  • Eosinophil count documented within 6 months of request

Treatment History:

  • High-dose inhaled corticosteroids tried and optimized
  • Additional controller medication used (LABA, LAMA, leukotriene modifier, or theophylline)
  • ≥2 asthma exacerbations requiring oral steroids in past 12 months OR ≥1 severe exacerbation
  • Continued maintenance therapy with ICS + controller documented

✅ Prescriber Requirements

  • Prescription from allergist/immunologist or pulmonologist (required by Aetna policy)
  • Specialist's DEA and NPI numbers available for forms

✅ Step Therapy Considerations

  • Preferred alternatives considered (Fasenra, Tezspire, Xolair may be required first)
  • Documentation of contraindications or failures to preferred agents if applicable

Coding & Billing Requirements

✅ ICD-10 Diagnosis Codes

  • J45.9 (Asthma, unspecified) - most common
  • J45.0 (Predominantly allergic asthma) - if applicable
  • M30.1 (Polyarteritis with lung involvement [EGPA]) - for EGPA cases

✅ HCPCS/J-Codes

  • J2182 confirmed for billing (Injection, mepolizumab, 1 mg)
  • Billing units calculated (1 unit = 1 mg administered)
  • NDC numbers documented (varies by formulation: vial vs. autoinjector)

✅ Administration Coding

  • CPT 96372 (therapeutic injection, subcutaneous) or 96401 (chemotherapy administration) identified
  • Modifiers ready (JW for wastage, JZ for no wastage, JG for 340B if applicable)

Documentation Packet

✅ Provider Note Elements

  • Complete medical history with asthma onset and progression
  • Current symptoms and functional limitations documented
  • Objective measures (spirometry, ACT/ACQ scores if available)
  • Prior therapy trials with dates, doses, and outcomes
  • Reason for Nucala selection over alternatives

✅ Letter of Medical Necessity Components

Use GSK's sample template and include:

  • Patient demographics and insurance information
  • Primary diagnosis with ICD-10 code
  • Clinical rationale for Nucala therapy
  • Documentation of failed prior treatments
  • Expected treatment goals and monitoring plan
  • Provider signature and credentials

✅ Required Attachments

  • Recent lab results (eosinophil count within 6 months)
  • Pulmonary function tests (if available)
  • Documentation of oral steroid use for exacerbations
  • Previous biologic trial records (if applicable)
  • Pharmacy records showing inhaled therapy compliance

Submission Process

✅ Form Selection & Completion

  • Correct Aetna precertification form downloaded (commercial form)
  • All required fields completed (incomplete forms cause delays)
  • Provider and patient signatures obtained

✅ Submission Methods

Primary Options:

  • Fax to 888-267-3277 (specialty medications)
  • Availity portal submission (fastest processing)
  • Phone: 866-752-7021 for urgent cases

Required Information:

  • Patient's member ID and group number
  • Prescriber's NPI and tax ID
  • Requested drug NDC and quantity
  • Site of care specified (physician office, infusion center)

✅ Common Rejection Prevention

  • Legible handwriting or typed forms
  • Complete contact information for follow-up
  • Correct diagnosis codes matching medical records
  • All attachments included in initial submission

Specialty Pharmacy Routing

✅ CVS Specialty Pharmacy Requirements

  • CVS Specialty confirmed as preferred vendor (typically required for Nucala)
  • Patient enrollment completed with CVS Specialty
  • Shipping address and preferences provided

✅ Transfer Process

  • Prescription transferred from retail pharmacy if needed
  • Prior authorization attached to specialty pharmacy order
  • Patient contacted by specialty pharmacy for coordination

✅ Delivery Verification

  • Shipment tracking number obtained
  • Delivery appointment scheduled (refrigerated medication)
  • Administration site prepared for receipt

After Submission: Tracking Your Request

✅ Confirmation & Follow-up

  • Confirmation number recorded from submission
  • Status check scheduled (call after 5-7 business days)
  • Additional information requests responded to promptly

✅ Timeline Expectations

  • Standard review: 30 days maximum
  • Expedited review: 72 hours (if urgent medical need)
  • Additional information requests: Can extend timeline

✅ Documentation

  • All communications logged with dates and reference numbers
  • Approval letter saved for pharmacy and future renewals
  • Denial letter preserved for potential appeals

Denial Prevention Tips

✅ Five Common Pitfalls & Solutions

Common Issue Prevention Strategy Documentation Needed
Insufficient eosinophil documentation Submit recent lab with exact cell count Lab report ≤6 months old showing ≥150 cells/µL
Missing step therapy evidence Document all prior controller failures Pharmacy records + clinical notes on intolerance/failure
Wrong prescriber specialty Ensure specialist prescribes Allergist/immunologist or pulmonologist DEA/NPI
Incomplete prior authorization form Use current form, complete all fields Current Aetna PA form
Non-formulary status confusion Request formulary exception Medical necessity letter explaining why alternatives failed

Pennsylvania Appeal Process

If your initial request is denied, Pennsylvania offers strong appeal protections:

✅ Internal Appeal (First Step)

  • File within 180 days of denial letter
  • Submit additional documentation addressing denial reasons
  • Request peer-to-peer review with Aetna medical director
  • Expect decision within 30 days (72 hours if expedited)

✅ Pennsylvania External Review (Second Step)

Pennsylvania's new Independent External Review Program has achieved a 50% overturn rate in 2024:

  • File within 4 months of final internal denial
  • Submit request via PA Insurance Department
  • Provide all documentation from internal appeals
  • Decision within 45 days (72 hours if expedited)
From our advocates: "We've seen several Pennsylvania Nucala denials overturned through the state's external review process when patients submitted comprehensive eosinophil count documentation and clear evidence of failed step therapy. The key is thorough documentation of medical necessity from the start."

Contact for Appeals:

  • Pennsylvania Insurance Department: 1-877-881-6388
  • Aetna Member Services: Number on your insurance card

Printable Checklist

Before You Start:

  • Insurance card and member ID ready
  • Recent lab results (eosinophil count)
  • List of all prior asthma medications tried
  • Specialist contact information

Documentation Gathering:

  • Medical records from specialist
  • Pharmacy records showing controller use
  • Emergency room/urgent care records for exacerbations
  • Any prior biologic therapy records

Submission Packet:

  • Completed Aetna PA form
  • Letter of medical necessity
  • Lab results (eosinophil count ≥150 cells/µL)
  • Treatment failure documentation
  • Provider prescription with NPI/DEA

After Submission:

  • Confirmation number recorded
  • Follow-up scheduled in 7 days
  • CVS Specialty Pharmacy enrollment completed
  • Appeal timeline noted (if needed)

Need help navigating this process? Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that align with each payer's specific requirements. Their platform analyzes denial letters and drafts point-by-point rebuttals using the right clinical evidence and procedural requirements for Pennsylvania appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance plan directly for personalized guidance. For additional help with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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