Nucala (mepolizumab) — United Healthcare

Initial criteria

• All of the following: patient established on therapy with Nucala under an active UnitedHealthcare medical benefit prior authorization for CRSwNP AND documentation of positive clinical response to Nucala therapy AND will continue as add-on maintenance therapy AND not receiving Nucala in combination with anti-interleukin 5 therapy [Cinqair, Fasenra], anti-IgE therapy [Xolair], anti-interleukin 4 therapy [Dupixent], or TSLP inhibitor therapy [Tezspire]
• OR all of the following: diagnosis of CRSwNP AND will be used as add-on maintenance therapy AND not receiving Nucala in combination with agents listed above

Reauthorization criteria

• Documentation of positive clinical response to Nucala therapy AND continued use as add-on maintenance therapy AND not receiving Nucala in combination with anti-interleukin 5 therapy, anti-IgE therapy, anti-interleukin 4 therapy, or TSLP inhibitor therapy

Approval duration

12 months