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ACCESS AND REIMBURSEMENT

Gateway to NUCALA offers resources and services to help meet the changing access needs of your patients

  • Patient-specific benefits investigations
  • Re-verification of benefits for annual health plan changes, if appropriate
  • Prior authorization research
  • Coding and billing details
  • Prescription referral triage to an in-network specialty pharmacy
  • Prior authorization tracking assistance
  • Claims appeals tracking assistance
  • Estimate of insurance coverage and cost-share information
  • Eligibility determinations for the NUCALA Co-pay Program and the Patient Assistance Program for Uninsured Patients
  • Alternative coverage research
  1. *Gateway services are not a guarantee of coverage or reimbursement. The decision by a payer to pay for a specific product is based on many factors. Providers should contact third-party payers for specific information on coding, coverage, or reimbursement.
  • Patients who need help affording or accessing their medication may be able to get assistance from Gateway to NUCALA.

  • NUCALA is available through a variety of distribution options.

    • All GSK-authorized specialty pharmacies, specialty distributors, and wholesalers are eligible to access NUCALA provided they service eligible customer classes
    • Fulfillment by participating network specialty pharmacies may vary based on health plan requirements

    When a physician, practice, or hospital outpatient department is not certain how to acquire NUCALA, Gateway to NUCALA can help to identify the available distribution options.

    ORDERING GUIDE >

    Find specialty pharmacies and distributors currently participating in the distribution network for NUCALA.

  • Billing and Coding Support

    Physician office

    Gateway to NUCALA can provide information about relevant codes for NUCALA, including product codes, procedure codes, NDC numbers, and revenue codes.

    Hospital outpatient department

    As with coding for services performed in the physician’s office, coding preferences and requirements in the hospital outpatient setting are dependent on payer type and plan type. Gateway to NUCALA can help identify coding requirements in both settings.

    Appeals research support

    If a patient is denied coverage for NUCALA, Gateway to NUCALA is available to research instances of coverage denial and identify steps practices can take to appeal claims. Gateway to NUCALA cannot author appeal letters on behalf of physicians. See sample letter of appeal below.

    Sample forms and letters

    When NUCALA is accessed throughout the patient treatment journey, a practice or hospital outpatient department may encounter the need for information on Centers for Medicare & Medicaid Services (CMS) Claim Forms 1500 and 1450, as well as appeal letters and letters of medical necessity. Details and examples of each are provided below.

    SAMPLE LETTER OF APPEAL >

    Illustrates information needed when appealing a denial of coverage for NUCALA.

    SAMPLE LETTER OF MEDICAL NECESSITY >

    Illustrates information regarding the medical rationale for choosing NUCALA.

    EXAMPLE OF CMS 1500 CLAIM FORM >

    Illustrates information generally required of physician offices by payers.

    EXAMPLE OF CMS 1450 CLAIM FORM >

    Illustrates information generally required of hospital outpatient offices by payers.

    1. The decision by a payer to pay for a specific product is based on many factors. It is always the prescriber’s responsibility to determine the appropriate treatment and submit appropriate codes, charges, and modifiers for treatments provided. Providers should contact third-party payers for specific information on their policies.

    Additional Coverage Resources

    Coverage can vary by plan and is dependent on medical necessity requirements. Gateway to NUCALA or the specialty pharmacy can help identify any patient-specific plan requirements and their possible coverage. In addition, CoverMyMeds® offers healthcare professionals support with Prior Authorization (PA) forms.

    CoverMyMeds® offers electronic PA forms for most prescription plans and is free to use.

    Benefits include:

    • Facilitates PA submissions
    • 10,000+ forms in one place
    • Works with all drugs, Medicare, Medicaid, and most commercial health plans
    • Complements Gateway to NUCALA services

    CoverMyMeds developed and maintains the CoverMyMeds website and is responsible for its content. Neither GSK nor CoverMyMeds can guarantee success in obtaining third-party coverage or reimbursement. It is always the healthcare provider's responsibility to provide and submit accurate and complete information. Providers should contact prescription health plans for specific information on their coding, coverage, and payment policies.

    All trademarks, trade names, and logos mentioned or used are the property of their respective owners. CoverMyMeds and GSK are not affiliated entities.

    Important Notice: Information regarding CoverMyMeds is brought to you as a courtesy of GSK.