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 severe asthma AND documentation of positive clinical response to Nucala therapy AND Nucala used in combination with maintenance controller medications [combination inhaled corticosteroid (ICS)/long-acting beta2 agonist (LABA), ICS, LABA] AND not receiving Nucala in combination with anti-interleukin 5 therapy [Cinqair (resilizumab), Fasenra (benralizumab)], anti-IgE therapy [Xolair (omalizumab)], anti-interleukin 4 therapy [Dupixent (dupilumab)], or TSLP inhibitor therapy [Tezspire (tezepelumab)]
• OR all of the following: diagnosis of severe asthma AND Nucala used in combination with maintenance therapy [Advair/AirDuo, Breo Ellipta, Symbicort, Trelegy Ellipta] AND asthma is an eosinophilic phenotype AND not receiving Nucala in combination with agents listed above

Reauthorization criteria

• Documentation of positive clinical response to Nucala therapy AND used in combination with maintenance therapy [Advair/AirDuo, Breo Ellipta, Symbicort, Trelegy Ellipta] 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