These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Mepolizumab (Nucala) is reserved for patient meeting all four criteria:
- Patient is followed by an asthma specialist, allergist, or pulmonologist and
- Patient is 12 years and older with a pre-treatment serum eosinophil count of 150 cells/mcL or greater at screening (within previous 6 weeks), and
- Patient has poor asthma control (see criteria #4) despite the following standard therapies:
- Regular use of inhaled steroids (such as Flovent);and
- Regular use of a long-acting beta-agonist (such as Serevent); and
- Regular or periodic use of oral steroids.
- Inadequate asthma control despite standard therapies is defined as one of the following:
All authorizations will be for one year. Renewals will be provided annually with documentation that the medication is effective.
Nucala is an interleukin-5 antagonist monoclonal antibody (IgG1 kappa) indicated for add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.
Limitations of Use:
- Not for treatment of other eosinophilic conditions.
- Not for relief of acute bronchospasm or status asthmaticus.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Injection, mepolizumab, 1 mg
100 mg single use vial
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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- Nucala Prescribing Information. Glaxo SmithKline LLC, Philadelphia, PA, November 2015