Description: Injection, mepolizumab, 1mg
Unit: 1 mg
Pay quarter: Q4 2023
Dosage and Frequency
• 100mg SQ every 4 weeks if patient's age is 12 years or older
• 40mg SQ every 4 weeks if patient's age is 6-11 years
• 100mg SQ every 4 weeks
hypereosinophilic syndrome (HES)
• 300mg SQ every 4 weeks
Calculate drug reimbursement
(ASP: $2,845.85, Margin: $170.75)
# Units to bill:100
Prior auth criteria for Nucala may include but is not limited to:
1. The patient must have a diagnosis of severe eosinophilic asthma, defined as eosinophil counts ?300 cells/microL and/or ?15% on peripheral blood smear.
2. The patient must have a history of inadequate asthma control despite a regimen of high dose inhaled corticosteroids and at least one additional controller medication.
3. The patient must be 12 years of age or older.
4. The patient must not have a history of life-threatening asthma exacerbations requiring hospitalization or emergency room visits within the past 6 months.
5. The patient must not have a history of myocardial infarction, stroke, or transient ischemic attack within the past 12 months.
6. The patient must not have an active infection or history of tuberculosis.
7. The patient must not have an immunodeficiency disorder or an immunosuppressive therapy.
8. The patient must not have an allergy to mepolizumab or any of its components.
Insurance prior auth guidelines: