By Counterforce Health Team in Nucala (mepolizumab) —

The Requirements Checklist to Get Nucala (Mepolizumab) Covered by UnitedHealthcare in Pennsylvania: Complete Guide with Forms and Appeals

Answer Box: Getting Nucala Covered by UnitedHealthcare in Pennsylvania

To get Nucala (mepolizumab) covered by UnitedHealthcare in Pennsylvania, you'll need: (1) Prior authorization through OptumRx with documented eosinophil count ≥150 cells/µL or ≥300 cells/µL within the past year, (2) Evidence of failed or inadequate response to standard maintenance therapy, and (3) Specialist evaluation from a pulmonologist, allergist, or immunologist. Submit via the UnitedHealthcare Provider Portal using form PA-Med-Nec-Nucala. If denied, Pennsylvania's new external review program has a 50% overturn rate for appeals.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Billing Requirements
  5. Documentation Packet Essentials
  6. Submission Process
  7. Specialty Pharmacy Coordination
  8. After Submission: What to Expect
  9. Common Denial Pitfalls to Avoid
  10. Pennsylvania Appeals Process
  11. Printable Quick Reference

Who Should Use This Checklist

This checklist is for Pennsylvania patients with severe eosinophilic asthma, EGPA, hypereosinophilic syndrome (HES), or chronic rhinosinusitis with nasal polyps (CRSwNP) who need Nucala coverage through UnitedHealthcare. You'll also find this useful if you're a clinician submitting prior authorization requests or appealing denials.

Expected Outcome: With proper documentation meeting UnitedHealthcare's criteria, initial approvals are common for patients with confirmed eosinophilic phenotypes. If denied, Pennsylvania's external review program has overturned approximately 50% of insurance denials in 2024.

Member & Plan Basics

Coverage Verification

  • ✅ Active UnitedHealthcare coverage with pharmacy benefits through OptumRx
  • ✅ Plan type confirmed: Commercial, Medicare Advantage, or Medicaid
  • ✅ Specialty drug coverage included (most plans cover Nucala on formulary with prior authorization)
  • ✅ Deductible status: High-deductible plans may require meeting deductible first

Authorization Requirements

UnitedHealthcare requires prior authorization for all Nucala indications through OptumRx. No exceptions for urgent start therapy—the PA must be approved before dispensing.

Clinical Criteria Requirements

Indication-Specific Requirements

Condition Key Requirements Lab Thresholds
Severe Eosinophilic Asthma Post-bronchodilator FEV1 30-70%; exacerbation history Eosinophils ≥300 cells/μL baseline
EGPA Eosinophilic vasculitis; specialist evaluation Blood eosinophils documented
HES Stable HES therapy 4+ weeks Eosinophils ≥1,000 cells/mcL
CRSwNP Chronic symptoms; prior surgery considered Clinical assessment

Source: UnitedHealthcare PA-Med-Nec-Nucala Form

Step Therapy Requirements

  • Standard maintenance therapy failure documented for asthma (high-dose ICS + LABA)
  • Cannot be used concurrently with Fasenra (benralizumab), Dupixent (dupilumab), or Tezspire (tezepelumab)
  • Previous biologic failure may strengthen approval chances but isn't required

Specialist Requirements

Prior authorization requests must come from qualified specialists:

  • Pulmonologist
  • Allergist/Immunologist
  • Rheumatologist (for EGPA)
  • Hematologist (for HES)
Note: Primary care providers can submit requests, but specialist evaluation must be documented in the clinical notes.

Coding & Billing Requirements

ICD-10 Diagnosis Codes

  • J82.83: Eosinophilic asthma (primary code for severe eosinophilic asthma)
  • J45.50: Severe persistent asthma, uncomplicated
  • J45.51: Severe persistent asthma with acute exacerbation
  • M30.1: Polyarteritis with lung involvement (EGPA)

HCPCS/J-Codes

Nucala is typically billed under:

  • J-code: Verify current HCPCS code with OptumRx (codes update annually)
  • NDC numbers: Varies by formulation (autoinjector vs. prefilled syringe)
  • Units: Based on prescribed dose (100mg standard for most indications)

Note: Specific J-codes should be verified with UnitedHealthcare's current fee schedule as these change annually.

Documentation Packet Essentials

Provider Note Requirements

Your physician's clinical note must include:

  • Specific diagnosis with ICD-10 code
  • Eosinophil count with date (≥150 cells/µL recent OR ≥300 cells/µL within past year)
  • Exacerbation history: Frequency, severity, hospitalizations
  • Current symptoms despite optimized therapy
  • Prior therapy details: Names, doses, duration, outcomes, reasons for discontinuation
  • Treatment goals and monitoring plan

Medical Necessity Letter Components

A strong medical necessity letter should address:

  1. Patient Background: Age, diagnosis, severity markers
  2. Clinical Rationale: Why Nucala is appropriate for this patient's phenotype
  3. Prior Therapy Documentation: Specific medications tried, doses, duration, and outcomes
  4. Laboratory Evidence: Recent eosinophil counts supporting eosinophilic phenotype
  5. Guideline Support: Reference to GINA guidelines or FDA labeling
  6. Monitoring Plan: How efficacy and safety will be assessed
Clinician Tip: GSK provides a sample medical necessity letter template that aligns with common payer requirements.

Required Attachments

  • Complete medical records (last 6-12 months)
  • Laboratory results showing eosinophil counts
  • Hospital records documenting exacerbations
  • Prescription history showing prior therapy trials
  • Specialist consultation notes
  • Pulmonary function tests (for asthma indications)

Submission Process

Correct Form and Portal

  • Form: Use PA-Med-Nec-Nucala (verify current version on UHC provider portal)
  • Submission: UnitedHealthcare Provider Portal (preferred) or phone 1-866-889-8054
  • Electronic PA: Available and offers faster processing than fax submissions

Required Fields That Commonly Cause Rejections

  • Patient demographics: Exact name matching insurance card
  • Provider NPI: Must match requesting physician
  • Diagnosis codes: Primary and secondary ICD-10 codes
  • Medication details: Exact NDC, dose, frequency, quantity
  • Clinical justification: Cannot be left blank or generic

Timeline Expectations

  • Standard review: 3-5 business days
  • Expedited review: 72 hours (for urgent clinical situations)
  • Additional information requests: 2-3 business days after submission

Specialty Pharmacy Coordination

UnitedHealthcare works with preferred specialty pharmacy networks for Nucala distribution:

Preferred Vendors

  • OptumRx Specialty Pharmacy
  • Accredo (Express Scripts network, if in-network)
  • Local specialty pharmacies (verify network status)

Transfer Process

  1. PA approval received: Pharmacy benefit confirmation
  2. Prescription routing: Send to network specialty pharmacy
  3. Patient enrollment: Specialty pharmacy contacts patient for delivery coordination
  4. First shipment: Verify receipt and proper storage
Important: Don't transfer prescriptions until PA approval is confirmed. Specialty pharmacies cannot dispense without active authorization.

After Submission: What to Expect

Confirmation and Tracking

  • Confirmation number: Record this for all follow-up calls
  • Status checks: Available through provider portal or member services
  • Documentation: Keep copies of all submitted materials

Response Timeline

Review Type Timeline Next Steps
Standard PA 3-5 business days Approval letter or denial with reason
Expedited PA 72 hours Clinical urgency documented
Additional Info Request 2-3 days to respond Submit missing documentation promptly

What to Record

  • Submission date and confirmation number
  • All communication dates and representatives spoken to
  • Any additional documentation requests
  • Approval or denial date and reference numbers

Common Denial Pitfalls to Avoid

Top 5 Denial Reasons and Prevention

Denial Reason How to Prevent
Insufficient eosinophil documentation Include recent lab values ≥150 cells/µL or historical ≥300 cells/µL
Missing step therapy documentation Document specific prior therapies with doses, duration, and outcomes
Non-specialist prescriber Ensure specialist evaluation is documented even if PCP submits
Incomplete clinical notes Include exacerbation history, current symptoms, treatment goals
Wrong diagnosis coding Use specific codes (J82.83 for eosinophilic asthma) not generic asthma codes

From our advocates: "We've seen the strongest approvals when providers include a clear timeline showing the patient's journey—when they started each therapy, how long they tried it, what specific outcomes occurred, and why they moved to the next option. Payers want to see that Nucala isn't a first choice, but a logical next step."

Pennsylvania Appeals Process

If your initial prior authorization is denied, Pennsylvania offers robust appeal rights with a high success rate.

Internal Appeal (Required First Step)

  1. File with UnitedHealthcare within 180 days of denial
  2. Submit additional documentation addressing denial reasons
  3. Await Final Adverse Benefit Determination letter

Pennsylvania External Review

Pennsylvania's Independent External Review Program launched in 2024 with impressive results:

  • Success rate: Approximately 50% of appeals overturned in favor of patients
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Deadline: 4 months from Final Adverse Benefit Determination letter

How to Submit External Review

  1. Complete internal appeal first and receive final denial letter
  2. Gather supporting documents: Medical records, physician certification form, insurance card
  3. Submit online at pa.gov external review portal
  4. Include additional evidence within 15 days of assignment to review organization

When to Request Expedited Review

Request expedited external review if:

  • Delay could seriously jeopardize your health
  • You're experiencing severe symptoms requiring immediate treatment
  • Standard timeline could result in permanent impairment

For assistance with appeals, contact the Pennsylvania Insurance Department's Office of Consumer Services or the Pennsylvania Health Law Project for free help with complex cases.

Printable Quick Reference

Pre-Submission Checklist

  • ☐ Active UnitedHealthcare coverage verified
  • ☐ Eosinophil count ≥150 cells/µL documented
  • ☐ Specialist evaluation completed
  • ☐ Prior therapy failures documented
  • ☐ Medical necessity letter drafted
  • ☐ All attachments gathered
  • ☐ Correct PA form completed
  • ☐ Submission method confirmed

Required Documentation

  • ☐ PA-Med-Nec-Nucala form (current version)
  • ☐ Medical necessity letter
  • ☐ Clinical notes (6-12 months)
  • ☐ Laboratory results (eosinophil counts)
  • ☐ Prescription history
  • ☐ Hospital/ER records (if applicable)
  • ☐ Specialist consultation notes
  • ☐ Pulmonary function tests (asthma cases)

After Denial Checklist

  • ☐ Review denial letter for specific reasons
  • ☐ Gather additional supporting documentation
  • ☐ File internal appeal within 180 days
  • ☐ Await Final Adverse Benefit Determination
  • ☐ File external review within 4 months (if needed)
  • ☐ Submit additional evidence within 15 days

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements, significantly improving approval rates for specialty medications like Nucala.

For additional support with UnitedHealthcare appeals in Pennsylvania, Counterforce Health can help identify the specific denial basis and draft point-by-point rebuttals that address payer requirements while incorporating the right clinical evidence and procedural documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and should not replace professional medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider for medical decisions. For personalized assistance with Pennsylvania insurance appeals, contact the Pennsylvania Insurance Department's consumer services line.

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