CurrentAnthemPolicy N/A

Nucala -Cardinal Care Medicaid PDF

Prior authorization form and requirements for NUCALA (mepolizumab) refilled autoinjector and syringe for Anthem HealthKeepers Plus Medicaid (Virginia). Defines clinical criteria for initial and renewal approvals across indications (severe eosinophilic asthma, EGPA, HES, CRSwNP), coadministration restrictions, required documentation and PA submission instructions.

Policy Summary

PayerAnthem

PolicyNucala -Cardinal Care Medicaid PDF

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionComplete one PA form per member with required clinical information and prescriber signature and fax to 844-512-7020; incomplete forms will delay the PA process.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes reported.

4Covered Indications (as listed)

6 moInitial approval duration (most indications)

12 moRenewal approval duration

>=150Asthma eosinophil threshold (cells/µL)

Policy summary

Prior authorization form and requirements for NUCALA (mepolizumab) refilled autoinjector and syringe for Anthem HealthKeepers Plus Medicaid (Virginia). Defines clinical criteria for initial and renewal approvals across indications including severe eosinophilic asthma, eosinophilic granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome (HES), and chronic rhinosinusitis with nasal polyps (CRSwNP), specifies coadministration restrictions with other biologics, outlines required documentation and assessment measures, and provides PA submission instructions including faxing the completed form. Initial approvals are generally for 6 months with renewals for 12 months.

Quick facts & thresholds

Covered Indications (as listed)4

Initial approval duration (most indications)6 months

Renewal approval duration12 months

Asthma eosinophil threshold (cells/µL)>=150

EGPA eosinophil threshold (absolute)>=1000 cells/µL

EGPA eosinophil threshold (percent)>=10%

Actions required of providers

Prior Authorization

Submit completed PA form

Complete one PA form per member. Include all required clinical information and the prescriber signature before submission. Fax the completed form to 844-512-7020. Incomplete, incorrect, or illegible forms will delay PA processing.

Documentation Required

Document baseline and response measures

Provide documentation of baseline disease severity and response measures as applicable to the indication. Examples include forced expiratory volume in 1 second (FEV1), Birmingham Vasculitis Activity Score (BVAS), hospitalizations, emergency department visits, unscheduled visits, blood eosinophil counts, CT scans, and disease activity scoring tools.

FEV1 (baseline and changes from baseline)
BVAS (for EGPA) and other disease activity scores
Hospitalizations, ER visits, and unscheduled visits
Blood eosinophil counts
CT scans (e.g., sinus opacifications for CRSwNP)

Billing Rule

Email opt-in for communications

Providers can sign up to receive email communications (including some messages sent in lieu of fax or mail) by enrolling at http://anthem.ly/signup-abcbs-va.

Denial Risk

Coadministration prohibited

Coadministration with the listed biologics is considered experimental and investigational by DMAS and is not permitted. Claims for therapies given in combination with Cinqair, Dupixent, Fasenra, Nucala, Tezspire, or Xolair risk denial.

Cinqair
Dupixent
Fasenra
Nucala
Tezspire
Xolair

Key definitions from form

Definitions

Severe asthmaAsthma that remains uncontrolled despite optimized treatment with high-dose ICS-LABA, requires high-dose ICS-LABA to prevent uncontrolled disease, or exhibits frequent symptoms/exacerbations or low FEV1; components listed are illustrative, not exhaustive.

EGPAEosinophilic Granulomatosis with Polyangiitis defined as history/presence of asthma, blood eosinophils >10% or >1000 cells/mm3, plus two or more specified clinical criteria (e.g., neuropathy, pulmonary infiltrates, cardiomyopathy, ANCA positivity).

HES flareWorsening of clinical signs and symptoms of HES or increasing eosinophils (on at least two occasions) resulting in need to increase oral corticosteroids or increase/add cytotoxic or immunosuppressive therapy.

FAQs / common questions

If operational questions arise, contact the payer’s provider line or follow the PA form instructions. Complete one PA form per member with required clinical information and the prescriber signature and fax the completed form to 844-512-7020; include requested documentation of baseline and response measures as applicable. Providers may also sign up for email communications via the form link/QR code on the PA form for additional PA notices.