Subject: Specialty Quantity Limit Nucala 2467-H P2026

Drug

NUCALA  (mepolizumab)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for all FDA-approved indications fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.

Covered Quantities

Medication	Standard Limit
Nucala (mepolizumab) 100 mg single-dose vial	3 vials per 28 days
Nucala (mepolizumab) 100 mg/mL single-dose prefilled syringe/autoinjector	3 syringes/autoinjectors per 28 days
Nucala (mepolizumab) 40mg/0.4 mL single-dose prefilled syringe	1 syringe per 28 days

FDA-Recommended Dosing

Severe Asthma

Age 12 years or older

100 mg every 4 weeks

Age 6 to 11 years

40 mg every 4 weeks

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

100 mg every 4 weeks

Eosinophilic Granulomatosis with Polyangiitis (EGPA) or Hypereosinophilic Syndrome (HES)

300 mg (three 100 mg injections) every 4 weeks

Chronic Obstructive Pulmonary Disease (COPD)

100 mg every 4 weeks

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Nucala [package insert]. Durham, NC: GlaxoSmithKline; August 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 16, 2026