By Counterforce Health Team in Increlex (mecasermin) —

How to Get Increlex (mecasermin) Covered by Aetna CVS Health in Pennsylvania: Forms, Appeals & Resources

Answer Box: Getting Increlex (mecasermin) Covered by Aetna CVS Health in Pennsylvania

Quick Path to Approval: Aetna requires prior authorization for Increlex (mecasermin) through CVS Specialty Pharmacy. Your endocrinologist must submit documentation proving severe primary IGF-1 deficiency with height ≥3 SD below normal and normal/elevated growth hormone levels. Start today: Have your doctor fax the completed Medical Exception/Prior Authorization form with lab results to 1-877-269-9916. If denied, Pennsylvania's new external review program overturns about 50% of appeals.

Table of Contents

Start Here: Verify Your Plan & Find the Right Forms

Before requesting coverage for Increlex (mecasermin), confirm your specific Aetna plan type. Pennsylvania residents may have:

  • Commercial Aetna plans (employer or individual)
  • Aetna Better Health (Pennsylvania Medicaid)
  • Aetna Medicare plans

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all plan types Aetna PA lists Aetna Precertification
Formulary Status Specialty tier, non-formulary on some plans Plan formulary Aetna Drug Guides
Prescriber Requirement Board-certified endocrinologist Medical policy Aetna CPB 0711
Age Restriction Children with open epiphyses only FDA labeling Aetna Medical Policy
Diagnosis Requirement Severe primary IGF-1 deficiency ICD-10 codes PA Health & Wellness Policy

Prior Authorization Forms & Requirements

Step-by-Step: Fastest Path to Approval

  1. Endocrinologist Consultation (Patient/Family)
    • Schedule with board-certified pediatric endocrinologist
    • Bring growth charts, previous lab results
    • Timeline: 2-4 weeks for appointment
  2. Diagnostic Testing (Endocrinologist)
    • IGF-1 levels (must be ≥3 SD below normal)
    • Growth hormone stimulation test (should show normal/elevated GH)
    • Bone age X-ray (confirm open epiphyses)
    • Timeline: 1-2 weeks for results
  3. Prior Authorization Submission (Endocrinologist's office)
    • Complete Medical Exception/PA form
    • Attach all supporting documentation
    • Submit via fax: 1-877-269-9916
    • Timeline: Same day submission
  4. Aetna Review Process
    • Standard review: 30-45 days
    • Expedited review: 72 hours (if urgent medical need)
    • Timeline: Decision notification by mail/phone

Required Clinical Documentation

Your endocrinologist must include:

  • Diagnosis confirmation: ICD-10 codes for severe primary IGF-1 deficiency
  • Lab results: Basal IGF-1 levels ≥3 SD below age/gender norms
  • Growth data: Height measurements ≥3 SD below normal
  • Growth hormone testing: Normal or elevated GH levels
  • Exclusion criteria: Documentation ruling out GH deficiency, malnutrition, hypothyroidism
  • Bone age: X-ray confirming open epiphyses
Clinician Corner: The medical necessity letter should emphasize that this is primary IGF-1 deficiency (not secondary to GH deficiency) and include specific lab values with reference ranges. Cite the FDA labeling for approved indications.

Submission Portals & Methods

Electronic Submission Options

  • Availity Portal: availity.com - Most efficient for PA requests
  • CoverMyMeds: Available for some Aetna plans
  • Phone Support: 1-855-240-0535 (Monday-Friday, 8 AM-6 PM CT)

Fax & Mail Backup

  • PA Fax: 1-877-269-9916 (24/7)
  • Appeals Fax: 1-866-235-5660
  • Mail Address:
    • Aetna Prior Authorization
    • PO Box 14079
    • Lexington, KY 40512
Tip: Always include a cover sheet with member ID, drug name (Increlex/mecasermin), and "URGENT - Pediatric Specialty Drug PA Request" for faster processing.

CVS Specialty Pharmacy Enrollment

Once Aetna approves your prior authorization, Increlex must be dispensed through CVS Specialty Pharmacy.

Enrollment Process

  1. Automatic Transfer: CVS Specialty will contact you within 24-48 hours of PA approval
  2. Manual Enrollment: Call 1-800-237-2767 or visit cvsspecialty.com
  3. Required Information:
    • Aetna member ID
    • Prescriber information
    • Delivery address
    • Preferred delivery schedule

What to Expect

  • Delivery: Temperature-controlled shipping to home or clinic
  • Supplies Included: Syringes, alcohol swabs, sharps container
  • Refill Management: Automatic refill coordination
  • Clinical Support: Injection training and adherence counseling

Support Lines & Contact Information

Member Services

  • General Aetna: 1-800-237-2767
  • CVS Specialty: 1-800-237-2767
  • PA Status Check: 1-855-240-0535

Provider Services

  • PA Submissions: 1-855-240-0535
  • Peer-to-Peer Reviews: Request through PA hotline
  • Appeals: 1-866-235-5660

What to Ask When Calling

  • "What's the status of my Increlex prior authorization?"
  • "Can you expedite this request due to growth delay?"
  • "What additional documentation do you need?"
  • "Can I request a peer-to-peer review with the medical director?"

Pennsylvania Appeals & External Review

If Aetna denies your Increlex request, Pennsylvania offers multiple appeal levels.

Internal Appeals (First Step)

Timeline: Submit within 60 days of denial Methods:

  • Online: my.aetna.com member portal
  • Fax: 1-866-235-5660
  • Phone: 1-800-237-2767

Required Documents:

  • Copy of denial letter
  • Additional medical records
  • Physician statement of medical necessity

Pennsylvania External Review (Final Step)

Pennsylvania's new Independent External Review Program has overturned approximately 50% of denials in its first year.

Eligibility: After receiving "Final Adverse Benefit Determination" from Aetna Timeline: Submit within 4 months of final denial Contact Information:

Decision Timelines:

  • Standard review: 45 days
  • Expedited review: 72 hours (life-threatening situations)
From Our Advocates: We've seen families successfully overturn Increlex denials by emphasizing that the child has primary IGF-1 deficiency (not GH deficiency) and including growth velocity data showing continued poor growth despite adequate nutrition. The key is distinguishing this rare condition from more common growth hormone deficiency.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Emphasize FDA-approved indication FDA labeling, endocrinologist letter
"Should try growth hormone first" Prove normal/elevated GH levels GH stimulation test results, IGF-1 levels
"Experimental/investigational" Cite FDA approval for primary IGFD FDA approval letter, medical literature
"Age restriction" Confirm open epiphyses Bone age X-ray, pediatric endocrine consultation
"Insufficient documentation" Submit complete clinical picture All lab results, growth charts, prior therapy records

Costs & Patient Assistance

Manufacturer Support

  • Ipsen Cares: Patient assistance program for eligible families
  • Contact: Visit ipsen.com for current program details
  • Eligibility: Typically income-based with insurance requirements

Additional Resources

  • HealthWell Foundation: May offer copay assistance for growth disorders
  • Pennsylvania CHIP: Additional coverage for qualifying children
  • Counterforce Health: Counterforce Health helps patients navigate insurance denials by creating targeted, evidence-backed appeals that turn denials into approvals, saving families time and reducing the stress of fighting for essential medications like Increlex.

FAQ

How long does Aetna CVS Health PA take in Pennsylvania? Standard prior authorization decisions are issued within 30-45 days. Expedited requests for urgent medical needs are decided within 72 hours.

What if Increlex is non-formulary on my plan? Request a formulary exception through your member portal or by calling 1-800-237-2767. Your endocrinologist must provide medical justification for why formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if your child's health is at serious risk due to delayed treatment. Your physician must complete a certification form documenting the urgent medical need.

Does step therapy apply to Increlex? Aetna may require documentation that growth hormone therapy is inappropriate (normal/elevated GH levels) before approving Increlex for primary IGF-1 deficiency.

What happens if I move within Pennsylvania? Your coverage continues uninterrupted. Contact CVS Specialty at 1-800-237-2767 to update your delivery address.

How often do I need reauthorization? Typically every 6 months, with documentation of positive response (increased growth velocity) and continued medical necessity.

Can I appeal to Pennsylvania if I have Medicare? No, Medicare appeals must go through the federal Medicare appeals process. Pennsylvania's external review is for commercial and Medicaid plans only.

What if my endocrinologist won't submit the PA? Seek a second opinion from a pediatric endocrinologist experienced with rare growth disorders. Counterforce Health can also help coordinate the necessary documentation and appeal process.

Disclaimer: 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 additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at (877) 881-6388 or visit pa.gov/insurance.

Sources & Further Reading

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