Nucala (mepolizumab) — Point32Health

Initial criteria

• Documented diagnosis of eosinophilic granulomatosis with polyangiitis
• Documentation the patient has at least two of the following disease characteristics: alveolar hemorrhage (by bronchoalveolar lavage) OR ANCA positive (Myeloperoxidase or proteinease 3) OR asthma OR biopsy containing a blood vessel with extravascular eosinophils OR cardiomyopathy (established by echocardiography or MRI) OR eosinophilia (≥10% eosinophils on differential leukocyte count) OR glomerulonephritis (hematuria, red cell casts, proteinuria) OR migratory or transient pulmonary infiltrates on chest x-rays OR neuropathy, mono or poly (motor deficit or nerve conduction abnormality) OR palpable purpura OR paranasal sinus abnormalities
• Patient age ≥ 18 years
• Prescribed by or in consultation with an allergist, immunologist, pulmonologist, or rheumatologist
• Documentation of one of the following: the patient is stable on corticosteroids OR contraindication to corticosteroids
• Documentation the patient’s disease has relapsed or is refractory to standard of care therapy (i.e., corticosteroid treatment with or without immunosuppressive therapy)

Reauthorization criteria

• Documented diagnosis of eosinophilic granulomatosis with polyangiitis
• Patient age ≥ 18 years
• Prescribed by or in consultation with an allergist, immunologist, pulmonologist, or rheumatologist
• Documentation the patient has experienced a therapeutic response as defined by at least one of the following: reduction in the frequency and/or severity of relapses OR reduction or discontinuation of doses of corticosteroids OR disease remission

Approval duration

initial 6 months; reauth 12 months