Nucala — Medical Mutual

Initial criteria

• Patient age ≥ 18 years; AND
• Diagnosis of chronic rhinosinusitis with nasal polyps via direct examination, endoscopy, or CT scan; AND
• Experienced ≥ 2 of: nasal congestion, nasal obstruction, nasal discharge, reduction/loss of smell for ≥ 12 weeks; AND
• Received ≥ 4 weeks of intranasal corticosteroid therapy AND will continue concomitantly with Nucala; AND
• EITHER received ≥ 1 course systemic corticosteroid for ≥ 5 days in previous 2 years OR has contraindication to systemic corticosteroid OR prior surgery for nasal polyps; AND
• Prescribed by or in consultation with allergist, immunologist, or otolaryngologist

Reauthorization criteria

• Already received ≥ 6 months of Nucala therapy; AND
• Continues therapy with intranasal corticosteroid; AND
• Responded to therapy as determined by prescriber (e.g., reduced polyp size, improved nasal congestion, reduced sinus opacification, improved sense of smell)

Approval duration

6 months initial; 1 year reauth