By Counterforce Health Team in Increlex (mecasermin) —

How to Get Increlex (mecasermin) Covered by Cigna in Illinois: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Increlex (mecasermin) Covered by Cigna in Illinois

Cigna requires prior authorization for Increlex (mecasermin) through a pediatric endocrinologist, typically placing it on Tier 4/5 specialty formularies. Your first step: verify your plan type (HMO requires PCP referral; PPO doesn't) and gather IGF-1 labs, growth charts showing height ≤-3.0 SD, and GH stimulation tests. Submit PA via Cigna's provider portal or fax with complete documentation. If denied, Illinois gives you 180 days for internal appeals and 4 months for external review through the Illinois Department of Insurance.

Take action today: Call the member services number on your Cigna ID card to confirm your plan's PA requirements and find in-network pediatric endocrinologists in Illinois.

Table of Contents

Plan Types & Referral Requirements

Your Cigna plan type determines whether you need a referral to see a pediatric endocrinologist for Increlex evaluation:

Plan Type PCP Required? Specialist Referral? Coverage Notes
HMO (Cigna Connect, Plus) Yes Yes - PCP must submit written referral In-network only; referral required before PA
PPO/Open Access No No - Direct access Highest flexibility; higher out-of-network costs
EPO Varies No - Network only No referrals typically needed
For HMO plans: Your PCP submits referrals via Cigna's provider portal, phone (1-866-494-2111), or fax (1-866-873-8279). The specialist must be in-network for coverage.

Formulary Status & Specialty Pharmacy

Increlex is typically placed on Tier 4 or Tier 5 (specialty/high-cost tiers) in Cigna formularies, requiring the highest copay or coinsurance. Verify your specific plan's coverage using Cigna's drug lookup tool.

Specialty Pharmacy Requirements

Cigna routes Increlex through Accredo, their specialty pharmacy partner. Retail pharmacies typically cannot dispense it due to storage requirements and monitoring needs.

Accredo enrollment process:

  1. Pediatric endocrinologist completes Accredo Prescription & Enrollment Form
  2. Fax to 888.302.1028 with insurance cards and clinical documentation
  3. Accredo coordinates PA with Cigna (2-3 business days standard)
  4. Ships to patient's home or provider office

Prior Authorization Requirements

Medical Necessity Criteria

Cigna requires documentation of severe primary IGF-1 deficiency in children ≥2 years old:

  • Height ≤-3.0 SD score on standardized growth charts
  • Consistently low IGF-1 levels (below 5th percentile for age/gender, ideally from ≥3 time points)
  • Normal or elevated growth hormone levels to exclude GH deficiency
  • Prescription by pediatric endocrinologist
  • Cannot be combined with recombinant growth hormone

Required Documentation

Your pediatric endocrinologist must submit:

  • Complete medical history and physical exam
  • Growth charts demonstrating poor growth velocity
  • Laboratory results (IGF-1, GH stimulation tests)
  • ICD-10 diagnosis codes
  • Medical necessity letter explaining why Increlex is appropriate
  • Documentation of contraindications to growth hormone therapy (if applicable)

Step-by-Step: Fastest Path to Approval

1. Verify Plan and Find Providers (You)

  • Call Cigna member services (number on ID card)
  • Confirm PA requirements and formulary tier
  • Use Cigna's provider directory to find in-network pediatric endocrinologists

2. Schedule Specialist Visit (You/PCP)

  • HMO plans: Request PCP referral first
  • PPO/EPO plans: Schedule directly with pediatric endocrinologist
  • Gather previous medical records, growth charts, and lab results

3. Complete Evaluation (Specialist)

  • Comprehensive assessment for IGF-1 deficiency
  • Order necessary labs (IGF-1, GH stimulation tests)
  • Document height/weight measurements and growth velocity

4. Submit Prior Authorization (Specialist)

  • Complete PA via Cigna provider portal or fax
  • Include all required documentation
  • Request expedited review if medically urgent (24-48 hour decision)

5. Coordinate with Accredo (Specialist)

  • Submit prescription and enrollment forms
  • Provide patient insurance information
  • Arrange delivery logistics

6. Track Status (You/Specialist)

  • Standard PA decisions: 15 business days
  • Check status via provider portal or member services
  • Follow up if no response within timeframe

7. Appeal if Denied (You/Specialist)

  • File internal appeal within 180 days
  • Provide additional documentation addressing denial reasons
  • Consider peer-to-peer review with Cigna medical director

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Not primary IGF-1 deficiency Demonstrate normal/elevated GH levels GH stimulation test results, endocrinologist letter
Insufficient growth data Provide comprehensive growth charts Serial height/weight measurements, growth velocity calculations
Missing lab values Submit complete IGF-1 testing Multiple IGF-1 levels over time, age-adjusted reference ranges
Step therapy required Document GH contraindication or failure Medical records, adverse reaction documentation
Quantity limits exceeded Justify dosing based on weight/BSA Dosing calculations, FDA prescribing information

Appeals Process in Illinois

Illinois provides strong patient rights for insurance appeals under the Health Carrier External Review Act.

Internal Appeals (Required First Step)

Timeline: 180 days from denial to file; 30 days for Cigna decision (expedited: 72 hours)

How to file:

  • Via Cigna appeals portal
  • Phone: Member services number on ID card
  • Written appeal to address on denial letter

What to include:

  • Copy of denial letter
  • Additional medical documentation
  • Medical necessity letter from specialist
  • Request for peer-to-peer review

External Review (After Internal Appeals)

Timeline: 4 months from final internal denial to file; 30 days for decision (expedited: 72 hours)

How to file:

Process:

  • Independent physician reviewer with relevant specialty expertise
  • Binding decision on Cigna
  • Fast-track available for urgent cases
From our advocates: We've seen families succeed by requesting peer-to-peer reviews during internal appeals. When the pediatric endocrinologist speaks directly with Cigna's medical director about the child's specific case and why Increlex is medically necessary, approval rates improve significantly. Don't skip this step—it's often the turning point.

Cost-Saving Options

Manufacturer Support

Ipsen CARES Patient Assistance Program

  • Copay assistance for commercially insured patients
  • Potential $0 copay for eligible patients
  • Apply at Ipsen's website (verify current link)

Financial Assistance

  • Contact Patient Advocate Foundation for copay assistance
  • Check eligibility for state pharmaceutical assistance programs
  • Explore hospital charity care programs if receiving care at academic medical centers

Frequently Asked Questions

How long does Cigna prior authorization take for Increlex? Standard PA decisions take 15 business days. Expedited reviews (for urgent cases) are decided within 24-48 hours.

What if Increlex is not on my Cigna formulary? You can request a formulary exception through your pediatric endocrinologist. Provide medical necessity documentation and evidence that formulary alternatives are inappropriate.

Can I appeal a Cigna denial myself? Yes, but having your pediatric endocrinologist lead the appeal with clinical documentation typically produces better results. You have the right to participate in all appeal processes.

Does Illinois have special protections for rare disease medications? Illinois' external review process requires physician reviewers with relevant specialty expertise, which helps ensure appropriate evaluation of rare disease cases like IGF-1 deficiency.

What happens if I miss the appeal deadline? Illinois allows 180 days for internal appeals and 4 months for external review. These are firm deadlines, so act promptly after any denial.

Can I get expedited review for my child? Yes, if delay would seriously jeopardize your child's health. Request expedited review in writing with supporting documentation from your pediatric endocrinologist.

When Insurance Denials Become Complex

Navigating insurance coverage for rare medications like Increlex can feel overwhelming, especially when dealing with prior authorizations and appeals. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and craft point-by-point rebuttals aligned to each plan's own rules.

The platform helps patients, clinicians, and specialty pharmacies by pulling the right citations—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaving them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and treatment goals. For medications like Increlex, this includes the operational details payers expect, such as proper dosing calculations and monitoring plans.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may vary by specific plan. Always verify current requirements with Cigna member services and consult with your healthcare providers for medical decisions. For assistance with Illinois insurance issues, contact the Illinois Department of Insurance at (877) 527-9431.

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