Is Nucala covered by Medicare?

In this article:

• How much does Nucala cost?
• Does Medicare cover Nucala?
• Cost of Nucala with Medicare
• How to save on Nucala with Medicare

In this article

• How much does Nucala cost?
• Does Medicare cover Nucala?
• Cost of Nucala with Medicare
• How to save on Nucala with Medicare

Breathing might seem simple, but it’s actually a series of intricate bodily functions, and when you throw severe asthma in the mix, it gets a lot more complicated. Fortunately, add-on maintenance treatments like Nucala (mepolizumab) are approved by the Food and Drug Administration to treat eosinophilic asthma, a condition where an overproduction of a certain type of white blood cells called eosinophils cause inflammation in the airways and asthma attacks. Nucala also treats conditions like chronic sinusitis with nasal polyps, a rare blood vessel disease called eosinophilic granulomatosis with polyangiitis, and a condition known as hypereosinophilic syndrome, where there are too many eosinophils in the blood. As a biologic drug, Nucala’s price might seem high. But there’s good news: That price can vary based on a range of factors, and some Medicare plans will cover it. 

How much does Nucala cost?

Nucala’s manufacturer, GlaxoSmithKline (GSK), says the drug’s list price is $3,689 for one dose, although the cost may vary based on dose and quantity. The manufacturer also notes that most people don’t pay the list price. Health insurance coverage and Medicare prescription drug plans might cover a substantial portion of the price. However, a patient’s out-of-pocket costs are also based on “whether they have satisfied their deductible and what kind of copays or co-insurance their policy carries along with it,” says Michael O. McKinney, MD, primary physician at Healthy Outlook.

Your out-of-pocket costs depend on where you get your prescription filled as well. Research has determined that prescription drug prices can vary significantly between pharmacies, even ones in the same town. According to Sazan Sylejmani, Pharm.D., “Prices can vary due to different pharmacy purchasing costs, regional pricing strategies, and the competitive landscape in specific areas.” Where you live can make a difference, too, as rural households spend slightly more on healthcare than urban ones, according to a study by Georgetown University.

The reason for Nucala’s high list price isn’t because of the drug itself but rather how it’s made. Most medications are synthetic, but pharmaceutical companies make biologics from living cells instead. This is a complicated, expensive, and time-consuming process, which drives up retail prices.

Does Medicare cover Nucala?

Some Medicare plans will cover Nucala, but others won’t. To know for sure, you’ll have to check the plan’s formulary—a drug list that shows how it covers each medication—or contact the insurance provider directly.

But even when it’s covered, there might be some extra steps involved. “Most insurance plans do cover [Nucala], but it is quite common for them to require prior authorization,” Dr. Sylejmani says. “This is a standard procedure to ensure that the prescribed medication is essential for the patient’s treatment plan and is used appropriately.”

Prior authorization can mean several different things. “Often there are certain criteria like showing evidence of severe persistent asthma despite the use of standard treatments,” Dr. McKinney says. If the Medicare provider signs off after receiving this additional information, you’ll receive coverage for Nucala.

Is Nucala covered by Medicare Part B?

Medicare Part B is responsible for inpatient treatments, but healthcare professionals administer some prescription drugs in their offices, putting them within Part B’s scope. “Medicare Part B can sometimes cover drugs like Nucala when administered in a doctor’s office, under the Durable Medical Equipment category, though it generally falls under Part D when prescribed for home use,” Dr. Sylejmani says.

According to data from the Centers for Medicare & Medicaid Services, Part B plans spent $232,903,955 covering Nucala in 2022.

Is Nucala covered by Medicare Part D?

For outpatient medications, Part D comprises standalone prescription drug plans that Medicare beneficiaries can add to their Part A or Part B plans. Medicare Advantage (Part C) plans also often include drug coverage. When doctors prescribe Nucala for at-home administration, it falls under Part D or the drug portion of a Medicare Advantage plan. Some plans will cover it, but others may not. In 2022, Part D plans paid out $193,350,671 to beneficiaries for their at-home Nucala treatment.  

Cost of Nucala with Medicare

When Medicare Part B covers a certain treatment or drug in a provider’s office, it requires 20% coinsurance. This means the plan will cover 80% of the cost, and the beneficiary or supplemental insurance has to pay the other 20%. Based on the $3,688.83 list price, 20% would be around $738 per dose.

Medicare Part D isn’t quite as straightforward. There are a variety of plans and no overarching policy on how much they will cover, so you’ll have to check your plan’s formulary to find out how much Nucala will cost you. Your costs also may be impacted by the coverage phase you are currently in, whether it’s the deductible phase, initial phase, coverage gap, or catastrophic phase.

How to save on Nucala with Medicare

Apart from insurance and Medicare drug coverage, there are several other ways to save money on Nucala. Here are a few of the most reliable:

1. Get a SingleCare discount card. SingleCare offers savings on thousands of medications, and they can significantly decrease out-of-pocket expenses. It’s free to sign up, and everyone is eligible—even if you already have Medicare. Just know that you can’t use SingleCare discounts on top of Medicare coverage. It has to be one or the other. Since Nucala is a limited availability drug, coupons aren’t always available, but check the drug’s SingleCare discount page periodically to confirm.
2. Apply for GSK’s patient assistance program. You may be eligible for free Nucala if your Medicare plan doesn’t cover it or if your copay is unaffordable. On top of that, eligible patients can’t receive assistance from any government programs like Medicaid, the VA, or TRICARE.
3. Look into Medicaid and Extra Help. If you meet certain income requirements, you may also be eligible for Medicaid—a federally and state-funded program that provides extra assistance to Medicare beneficiaries. Each state has its own Medicaid policies and enrollment procedures, so check with your state to see if you qualify. Medicare also has a program called Extra Help, which provides assistance in paying for medications. Anyone enrolled in Medicaid and certain other programs automatically qualifies for Extra Help.
4. Ask for a 90-day supply. If you handle the drug administration at home, your healthcare provider might be open to writing a prescription for a 90-day supply instead of a 30-day supply. Studies have shown that patients who got 90-day prescriptions saved more than those who got 30-day prescriptions—and stuck to their medication regimen better.