By Counterforce Health Team in Increlex (mecasermin) —

How Long Does It Take to Get Increlex (mecasermin) Approved by Blue Cross Blue Shield in Washington? Timeline & Milestones

Quick Answer: Increlex (mecasermin) Approval Timeline in Washington

Standard approval timeline: 3-14 business days for complete Blue Cross Blue Shield prior authorization submissions in Washington. Expedited review: 24-72 hours for urgent cases where delay could jeopardize patient health. Key factors affecting timing: completeness of IGF-1 deficiency documentation, bone age studies, and endocrinologist prescription. Start today: Verify your child meets criteria (age 2-18, height ≤ -3.0 SD, IGF-1 ≤ -3.0 SD) and gather growth hormone levels showing normal/elevated results.

Table of Contents

What Affects Approval Timing

Several factors determine how quickly Blue Cross Blue Shield processes your Increlex (mecasermin) prior authorization in Washington:

Benefit Type & Complexity

  • Medical benefit (physician-administered): typically faster review
  • Pharmacy benefit (self-administered): may require additional specialty pharmacy coordination
  • Complex cases with multiple diagnoses: extended review period

Completeness of Documentation The most common cause of delays is incomplete submissions. Blue Cross Blue Shield requires:

  • Height standard deviation score ≤ -3.0
  • IGF-1 standard deviation score ≤ -3.0
  • Normal or elevated growth hormone levels
  • Delayed bone age documentation
  • Endocrinologist prescription
  • Patient age verification (2-18 years old)

Washington State Processing Requirements Washington regulations require Blue Cross plans to process standard prior authorization requests within 1-3 business days for electronic submissions and 3-5 business days for faxed submissions.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Clinical Requirements:

  • Growth chart showing height ≤ -3.0 standard deviations
  • IGF-1 lab results ≤ -3.0 standard deviations
  • Growth hormone stimulation test results (normal/elevated)
  • Bone age X-ray with radiologist interpretation
  • Endocrinologist consultation notes
  • ICD-10 diagnosis code E34.3 (Short stature due to endocrine disorder)

Administrative Items:

  • Blue Cross Blue Shield member ID and policy details
  • Prior authorization form completion
  • Provider NPI and contact information
  • Preferred pharmacy information (if self-administered)
Tip: Use the Blue Cross Blue Shield provider portal to verify current prior authorization requirements before submission.

Submission to Initial Review (1-5 Days)

Standard Processing Timeline

Electronic Submission (Recommended):

  • Portal submission: 1-3 business days
  • Automatic acknowledgment within 24 hours
  • Clinical review begins immediately

Fax Submission:

  • Processing time: 3-5 business days
  • Manual entry required
  • Higher risk of documentation errors

What Reviewers Check First

  1. Patient eligibility and active coverage
  2. Age requirements (2-18 years old)
  3. Diagnosis confirmation (severe primary IGF-1 deficiency)
  4. Prescriber qualifications (endocrinologist requirement)
  5. Laboratory values meeting specific thresholds

Counterforce Health helps families navigate these complex prior authorization requirements by automatically identifying the specific criteria your Blue Cross plan uses and ensuring all documentation aligns with their policies.

Additional Information Requests (1-7 Days)

If Blue Cross Blue Shield requests additional information, respond within 5 business days to avoid delays. Common requests include:

Missing Laboratory Data:

  • IGF-1 levels with reference ranges
  • Growth hormone stimulation test details
  • Thyroid function studies (to rule out hypothyroidism)

Incomplete Growth Documentation:

  • Serial height measurements over 6-12 months
  • Growth velocity calculations
  • Bone age progression studies

Safety Monitoring Plans:

  • Hypoglycemia prevention protocol
  • Regular funduscopic examination schedule
  • Glucose monitoring frequency
Note: Incomplete responses restart the review clock, potentially adding 5-10 business days to your approval timeline.

Decision Window & Outcomes

Typical Approval Scenarios

Standard Approval (60-70% of cases):

  • Complete documentation submitted
  • Clear IGF-1 deficiency diagnosis
  • All safety criteria met
  • Duration: typically 12 months

Conditional Approval (15-20% of cases):

  • Additional monitoring required
  • Dose limitations imposed
  • Quarterly progress reports mandated

Denial (15-25% of cases):

  • Insufficient growth hormone testing
  • Alternative diagnosis suspected (GH deficiency, malnutrition)
  • Missing endocrinologist evaluation
  • Safety concerns (e.g., closed epiphyses)

Reading Your Approval Letter

Look for these key details:

  • Approval duration (usually 12 months)
  • Quantity limits (typically up to 0.12 mg/kg twice daily)
  • Site of care restrictions (home vs. clinic administration)
  • Monitoring requirements (lab frequency, specialist visits)

If Denied: Appeal Timeline

Washington state provides robust appeal rights for Blue Cross Blue Shield denials:

Internal Appeal Process

  • Deadline: 60 days from denial notice
  • Response time: 30 days for standard cases, 72 hours for urgent
  • Required documents: Original PA request, denial letter, additional clinical evidence

External Review Process

If internal appeal fails, you can request an Independent Review Organization (IRO) review:

  • Deadline: 60 days from final internal denial
  • Review timeline: 20 days for standard cases, 72 hours for expedited
  • Binding decision: IRO ruling is enforceable against the insurer

Washington Office of Insurance Commissioner Support

Contact the OIC Consumer Advocacy line at 1-800-562-6900 for assistance with appeals. They provide template letters and can help navigate the process.

Renewal Cycles & Reauthorization

Annual Reauthorization Requirements

Blue Cross Blue Shield requires yearly reauthorization for continued Increlex coverage:

Growth Response Documentation:

  • Minimum 2 cm growth in prior year
  • Updated bone age studies showing open epiphyses
  • Current height and IGF-1 measurements

Safety Monitoring Results:

  • Glucose tolerance assessments
  • Ophthalmologic examinations
  • Absence of contraindications (tumors, intracranial pressure)

Timeline for Renewals:

  • Submit 30-45 days before current authorization expires
  • Standard processing: 5-10 business days (faster than initial requests)
  • Continuous therapy maintained during review period

Timeline Visual & Milestones

Phase Days Key Activities Expected Outcome
Preparation 0-2 Gather documentation, complete forms Ready to submit
Initial Review 1-5 Portal submission, eligibility check Acknowledgment received
Clinical Review 3-10 Medical necessity assessment Decision or info request
Additional Info 1-7 Respond to requests (if needed) Complete file ready
Final Decision 1-3 Approval letter issued Coverage begins
Total Timeline 5-14 days Complete process Approved & Active

Expedited cases: 24-72 hours total

Time-Saving Tips

Portal Usage Best Practices

  • Submit electronically through the Blue Cross provider portal
  • Upload all documents in a single submission
  • Use high-resolution scans for lab reports and X-rays
  • Include cover letter summarizing medical necessity

Bundled Evidence Strategy

Organize documentation by category:

  1. Diagnostic evidence: IGF-1 labs, growth charts, bone age
  2. Treatment rationale: Endocrinologist notes, failed alternatives
  3. Safety planning: Monitoring protocols, risk mitigation

Direct Specialty Routing

For complex cases, request direct routing to the pediatric endocrine reviewer rather than general medical management.

Counterforce Health's platform streamlines this entire process by automatically organizing your clinical evidence according to Blue Cross Blue Shield's specific criteria and generating targeted prior authorization requests that address each requirement systematically.

FAQ

How long does Blue Cross Blue Shield PA take in Washington? Standard processing is 3-14 business days for complete submissions. Electronic submissions through the provider portal are fastest at 1-3 days.

What if Increlex is non-formulary on my plan? Most Blue Cross plans cover Increlex as a specialty medication with prior authorization. Non-formulary status may require a formulary exception request with additional clinical justification.

Can I request expedited review for Increlex? Yes, if delay could seriously jeopardize your child's health or development. Mark the submission as "urgent" and provide clinical documentation supporting the time-sensitive nature.

Does step therapy apply to Increlex? Some plans require documented failure of growth hormone therapy first, unless contraindicated. Check your specific plan's medical policy for step therapy requirements.

What happens if I move to another state during treatment? Coverage may vary between Blue Cross plans in different states. Contact your new plan's customer service to ensure continuity of coverage and transfer medical records.

How much does Increlex cost without insurance? Retail prices can exceed $16,000 per 4 mL vial. Ipsen offers patient assistance programs—check their website for current eligibility requirements and application process.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with prior authorization requests and appeals, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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