CurrentCommunity-CarePolicy N/A

Mepolizumab (medical benefit) utilization — coverage criteria

This policy defines medical necessity criteria, quantity limits, authorization periods, and prescribing requirements for mepolizumab across multiple eosinophil-related indications for Community-Care members.

Policy Summary

PayerCommunity-Care

PolicyMepolizumab (medical benefit) utilization — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 1, 2025

Key ActionObtain prior authorization with indication-specific criteria met and required documentation including specialist involvement, eosinophil count, exacerbation history, and prior therapy trials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5indications covered

100 mgusual dose (asthma/CRSwNP/COPD)

300 mgdose (EGPA/HES)

6 moinitial auth period

oftenspecialist required

Coverage and Medical Necessity Criteria

Initial Approval — Asthma

Covered when ALL of the following are met

Asthma initial criteria: Patient is >= 6 years of age; prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist; diagnosis of severe asthma; diagnosis of eosinophilic asthma with a provided baseline blood eosinophil concentration >= 150 cells/µL; history of >= 2 asthma exacerbations requiring systemic corticosteroids or emergency department visit or hospitalization for treatment of asthma within the past year despite adherent utilization of either an inhaled corticosteroid (ICS) with 1 additional asthma controller medication or maximally tolerated inhaled corticosteroid/long-acting beta agonist (ICS/LABA) combination product; prescriber attests that the patient is adherent to controller medications and that mepolizumab will not be used in combination with another targeted immunomodulator product used for asthma.age >=6; eos >=150; >=2 exacerbations

Prescriber attestation required regarding adherence and non-concomitant targeted immunomodulator use

Initial Approval — Chronic rhinosinusitis with nasal polyps (CRSwNP)

Covered when ALL of the following are met

Policy Summary

PayerCommunity-Care

PolicyMepolizumab (medical benefit) utilization — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateDec 1, 2025

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial Approval — Eosinophilic granulomatosis with polyangiitis (EGPA)

Covered when ALL of the following are met

EGPA initial criteria: Patient is >= 18 years of age; prescribed by, or in consultation with, a rheumatologist, allergist, pulmonologist, or immunologist; diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA); one of the following baseline blood eosinophil criteria: > 1000 cells/µL OR > 10% of the total leukocyte count; trial of oral corticosteroid therapy equivalent to prednisone 7.5 mg/day for a minimum of 4 weeks was ineffective, contraindicated, or not tolerated.age >=18; eos >1000 or >10%

Specialist involvement and corticosteroid trial required

Initial Approval — Hypereosinophilic Syndrome (HES)

Covered when ALL of the following are met

HES initial criteria: Prescribed by, or in consultation with, a rheumatologist, allergist, pulmonologist, gastroenterologist, hematologist, or other specialist experienced in HES; patient is >= 12 years of age; diagnosis of hypereosinophilic syndrome (HES) without clinical features consistent with a myeloid disorder; HES has persisted for at least 6 months; blood eosinophils > 1000 cells/µL; >= 2 HES flares within the past 12 months; trial of corticosteroids and/or second-line steroid-sparing agent (eg hydroxyurea or interferon alfa) was ineffective, not tolerated, or contraindicated.age >=12; eos >1000; >=2 flares in 12 months; duration >=6 months

Specialist involvement and prior therapy required

Initial Approval — Chronic Obstructive Pulmonary Disease (COPD)

Covered when ALL of the following are met

COPD initial criteria: Prescribed by, or in consultation with, an allergist, pulmonologist, or immunologist; diagnosis of chronic obstructive pulmonary disease (COPD) with eosinophilic phenotype and a provided baseline blood eosinophil concentration >= 300 cells/µL; history of >= 2 moderate COPD exacerbations or >= 1 severe COPD exacerbation within the past year despite adherent utilization of maintenance triple therapy (LAMA/LABA/ICS); will not be used in combination with another targeted immunomodulator product used for COPD or asthma.eos >=300; >=2 moderate or >=1 severe exacerbation

Specialist involvement and adherence to triple therapy required

Continuation of Therapy

Covered when ALL of the following are met (per-indication)

Asthma continuation: Diagnosis of eosinophilic asthma; positive clinical response has been achieved; will not be used in combination with another targeted immunomodulator product used for asthma.positive clinical response

Continuation requires documented benefit

CRSwNP continuation: Diagnosis of chronic rhinosinusitis with nasal polyposis; positive clinical response has been achieved.positive clinical response

Continuation requires documented benefit

EGPA continuation: Diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA); positive clinical response has been achieved.positive clinical response

Continuation requires documented benefit

HES continuation: Diagnosis of hypereosinophilic syndrome (HES) without clinical features consistent with a myeloid disorder; positive clinical response has been achieved.positive clinical response

Continuation requires documented benefit

COPD continuation: Diagnosis of chronic obstructive pulmonary disease (COPD); positive clinical response with use of mepolizumab has been achieved; will not be used in combination with another targeted immunomodulator product used for COPD or asthma.positive clinical response

Continuation requires documented benefit

Coverage requires appropriate specialist involvement and documentation specific to each indication. For asthma and COPD, prescriptions must be written by or in consultation with an allergist, pulmonologist, or immunologist. EGPA and HES require specialist prescribing or consultation (EGPA: rheumatologist, allergist, pulmonologist, or immunologist; HES: a specialist experienced in HES such as rheumatologist, allergist, pulmonologist, gastroenterologist, or hematologist).

Eosinophil thresholds and exacerbation history are required where specified: for eosinophilic asthma a baseline blood eosinophil concentration of ≥ 150 cells/µL; for COPD an eosinophil concentration of ≥ 300 cells/µL; for EGPA and HES blood eosinophils must exceed intense thresholds (EGPA: > 1000 cells/µL or >10% of total leukocytes; HES: > 1000 cells/µL).

Prior therapy trials are also required per indication and must be documented: asthma requires prior use of an inhaled corticosteroid plus an additional controller or maximally tolerated ICS/LABA; CRSwNP requires trial of a nasal corticosteroid spray; EGPA requires a trial of oral corticosteroid therapy equivalent to prednisone 7.5 mg/day for ≥4 weeks; HES requires trial of corticosteroids and/or second‑line steroid‑sparing agents; COPD requires adherent use of maintenance triple therapy (LAMA/LABA/ICS). Where continuation is requested, documentation of a positive clinical response is required.

Billing and Laboratory Thresholds

Applicable HCPCS CodeHCPCS

J2182

Injection, mepolizumab, 1 mg

Asthma eosinophil threshold

Asthma eosinophil threshold>= 150 cells/µL

Applies toInitial approval for eosinophilic asthma (age >= 6 years)

Documented asBaseline blood eosinophil concentration must be provided

COPD eosinophil threshold

COPD eosinophil threshold>= 300 cells/µL

Applies toInitial approval for eosinophilic COPD phenotype

Prescriber requirementPrescribed by or in consultation with an allergist, pulmonologist, or immunologist

EGPA eosinophil criteria

EGPA eosinophil criteria> 1000 cells/µL OR > 10% of total leukocyte count

Applies toInitial approval for eosinophilic granulomatosis with polyangiitis (EGPA)

Additional requirementTrial of oral corticosteroid therapy (prednisone 7.5 mg/day equivalent for >=4 weeks) required unless ineffective, contraindicated, or not tolerated

HES eosinophil threshold

HES eosinophil threshold> 1000 cells/µL

Applies toInitial approval for hypereosinophilic syndrome (HES)

Additional requirementsHES persistent >= 6 months and >=2 HES flares in past 12 months; specialist involvement required

Prior Authorization, Documentation, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required for mepolizumab (HCPCS code J2182). Requests must include a clear indication and supporting documentation as outlined below. Submit prior authorization requests per payer procedures before drug administration or billing.

HCPCS: J2182 (Injection, mepolizumab, 1 mg)

Step Therapy

Required Prior Therapy Trials

Prior therapy trials are required for initial approval and must be documented in the prior authorization request. For asthma: trial and continued use of an inhaled corticosteroid (ICS) plus at least one additional controller medication, or maximally tolerated ICS/LABA combination therapy, with persistent exacerbations despite adherence. For chronic rhinosinusitis with nasal polyps: trial of a nasal corticosteroid spray that was ineffective, contraindicated, or not tolerated. For EGPA and HES: trial of systemic corticosteroid therapy (EGPA: prednisone ≈7.5 mg/day for ≥4 weeks) or other steroid-sparing agents for HES unless contraindicated or not tolerated. For COPD: adherence to maintenance triple therapy (LAMA/LABA/ICS) with persistent exacerbations.

Asthma: documentation of adherence to ICS + 1 additional controller or maximally tolerated ICS/LABA and ≥2 exacerbations in past year despite therapy
CRSwNP: trial of nasal corticosteroid spray ineffective, contraindicated, or not tolerated
EGPA: trial of oral corticosteroid therapy (prednisone ≈7.5 mg/day for ≥4 weeks) ineffective, contraindicated, or not tolerated
HES: trial of corticosteroids and/or steroid-sparing agent ineffective, contraindicated, or not tolerated
COPD: adherence to maintenance triple therapy (LAMA/LABA/ICS) with ≥2 moderate or ≥1 severe exacerbation in past year

Documentation Required

Required Documentation

Prescriber specialty and baseline clinical data must be provided with the authorization request. Required documentation includes age, specialty prescriber or documented consultation, confirmed diagnosis, and baseline blood eosinophil concentration where applicable. Also include prior exacerbation history, trials of prior therapies, and attestation that mepolizumab will not be used concurrently with another targeted immunomodulator for the same condition.

Age of patient
Specialist prescriber or documented consultation (allergist, pulmonologist, immunologist, rheumatologist, otolaryngologist, hematologist, or other appropriate specialist as indicated)
Confirmed diagnosis relevant to the requested indication (e.g., eosinophilic asthma, CRSwNP, EGPA, HES, COPD)
Baseline blood eosinophil concentration (e.g., ≥150 cells/µL for asthma; ≥300 cells/µL for COPD; thresholds per indication)
History of exacerbations and prior medication trials (see prior therapy trials)
Prescriber attestation of adherence to controller medications and that therapy will not be combined with another targeted immunomodulator

Denial Risk

Denial Triggers

Authorization may be denied if required criteria or documentation are not met. Common reasons for denial include lack of specialist involvement or documented consultation, failure to meet eosinophil or exacerbation thresholds, inadequate or undocumented trials of prior therapies, use in combination with another targeted immunomodulator, or missing baseline laboratory data.

No specialist prescriber or no documented consultation when required
Baseline blood eosinophil concentration below indication-specific threshold or not provided
Insufficient history of exacerbations or failure to document prior controller therapy trials
Use in combination with another targeted immunomodulator for asthma/COPD
Missing documentation of prior steroid trials or intolerance/contraindication when required

OpenPayer

Mepolizumab (medical benefit) utilization — coverage criteria

Coverage and Medical Necessity Criteria

Billing and Laboratory Thresholds

Prior Authorization, Documentation, and Denial Triggers

Background

Key Definitions