By Counterforce Health Team in Increlex (mecasermin) —

How to Get Increlex (Mecasermin) Covered by Cigna in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Increlex (Mecasermin) Covered by Cigna in New York

Yes, Cigna covers Increlex (mecasermin) with prior authorization for severe primary IGF-1 deficiency in children age 2+. The fastest path: Your pediatric endocrinologist submits a prior authorization request with lab results (IGF-1 ≤-3.0 SD, normal/elevated GH), growth charts (height ≤-3.0 SD), and x-rays showing open growth plates. Approval typically takes 1-2 business days with complete documentation. If denied, you have 180 days to appeal internally, then 4 months for external review through New York DFS, which overturns ~50% of specialty drug denials.

Start today: Call your pediatric endocrinologist to begin the prior authorization process and ensure all required lab work is current.

Table of Contents

  1. Coverage Basics: Is Increlex Covered by Cigna?
  2. Prior Authorization Process: Who Submits and How
  3. Timeline: How Long Does Approval Take?
  4. Medical Necessity Criteria: What Documentation is Required
  5. Costs and Financial Assistance
  6. Denials and Appeals: Your Rights in New York
  7. Renewal Requirements: Maintaining Coverage
  8. Specialty Pharmacy: Accredo Enrollment Process
  9. Common Problems and Solutions
  10. Frequently Asked Questions

Coverage Basics: Is Increlex Covered by Cigna?

Cigna does cover Increlex (mecasermin) for pediatric patients with severe primary IGF-1 deficiency, but it requires prior authorization and strict adherence to FDA-approved criteria. The medication is typically managed through Cigna's specialty pharmacy network, primarily Accredo.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all patients Cigna Policy CNF-383
Age Restriction Must be at least 2 years old FDA Label
Specialist Requirement Pediatric endocrinologist prescription Cigna Policy
Diagnosis Severe primary IGF-1 deficiency only FDA Indication
Formulary Status Specialty tier (non-formulary exceptions available) Exception Process

Prior Authorization Process: Who Submits and How

Step-by-Step: Fastest Path to Approval

  1. Pediatric Endocrinologist Evaluation (Patient + Provider)
    • Complete diagnostic workup including IGF-1 levels, growth hormone stimulation test, and bone age x-ray
    • Expected timeline: 1-2 weeks for all testing
  2. Prior Authorization Submission (Provider)
  3. Specialty Pharmacy Enrollment (Provider + Patient)
    • Complete Accredo referral form (fax: 888.302.1028)
    • Provide insurance cards and clinical documentation
    • Expected timeline: 2-3 business days for enrollment
  4. Delivery Setup (Patient + Accredo)
    • Schedule home delivery with temperature-controlled shipping
    • Receive injection training and supplies
    • Expected timeline: 3-5 business days for first shipment
Tip: Start the process 2-3 weeks before you need the medication to account for potential delays or additional documentation requests.

Timeline: How Long Does Approval Take?

Standard Review: 1-2 business days once Cigna receives complete documentation Expedited Review: 24 hours for urgent medical situations Specialty Pharmacy Processing: Additional 2-3 business days after approval

When to Request Expedited Review

  • Current treatment with Increlex being discontinued
  • Severe growth delay requiring immediate intervention
  • Patient health at serious risk without treatment

Contact Cigna at 866.494.2111 to request expedited review with clinical justification from your provider.

Medical Necessity Criteria: What Documentation is Required

Clinician Corner: Medical Necessity Letter Checklist

Your pediatric endocrinologist must document:

Required Lab Values:

  • IGF-1 standard deviation score ≤ -3.0
  • Normal or elevated growth hormone levels (rules out GH deficiency)
  • Current height standard deviation score ≤ -3.0

Clinical Documentation:

  • ICD-10 diagnosis code for severe primary IGF-1 deficiency
  • Growth charts showing poor growth velocity
  • Bone age x-ray confirming open epiphyses
  • Previous treatments tried (if any) and outcomes

Safety Monitoring Plan:

Exclusion Criteria Addressed:

  • Rule out secondary IGF-1 deficiency (malnutrition, hypothyroidism)
  • Confirm no active malignancy
  • Document patient not receiving concurrent growth hormone therapy
Note: Cigna aligns with FDA labeling restrictions. Off-label use for idiopathic short stature or secondary IGF-1 deficiency will be denied.

Costs and Financial Assistance

Increlex costs approximately $16,000 per 4 mL vial at retail prices. Your out-of-pocket costs depend on your specific Cigna plan's specialty drug coverage.

Savings Options

Manufacturer Support:

State Programs:

  • New York State of Health premium tax credits for eligible families
  • Medicaid coverage available for qualifying income levels

Foundation Grants:

  • Patient Advocate Foundation
  • NeedyMeds database of assistance programs

Contact Accredo's financial counseling team at 877.826.7657 to explore all available options.

Denials and Appeals: Your Rights in New York

Common Denial Reasons & How to Overturn Them

Denial Reason Required Documentation Action Steps
"Not primary IGF-1 deficiency" Lab results showing normal/elevated GH, rule out secondary causes Submit complete endocrine workup with specialist interpretation
"Insufficient lab documentation" IGF-1 and GH levels with reference ranges Provide lab reports with standard deviation scores clearly marked
"Safety concerns" Missing hypoglycemia monitoring plan Submit detailed monitoring protocol per FDA requirements
"Quantity limits exceeded" Clinical justification for dosing Document weight-based dosing calculations and titration plan

Appeals Playbook for Cigna in New York

Level 1: Internal Appeal

  • Deadline: 180 calendar days from denial
  • How to file: Cigna member portal or mail to address on denial letter
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: Medical records, provider letter, clinical literature

Level 2: External Review (New York DFS)

  • Deadline: 4 months after final internal denial
  • How to file: New York DFS External Appeal Program
  • Fee: $25 (refunded if you win)
  • Timeline: 30 days standard, 72 hours expedited (24 hours for urgent drug denials)
  • Success Rate: Approximately 50% of specialty drug denials are overturned
Critical: New York's external appeal process is binding on Cigna. Independent medical experts review your case using current medical literature and specialty guidelines.

When to Escalate

Contact the New York Department of Financial Services Consumer Hotline at 1-800-342-3736 if:

  • Cigna fails to meet appeal deadlines
  • You suspect improper denial practices
  • You need help navigating the external review process

Renewal Requirements: Maintaining Coverage

Cigna requires annual reauthorization for continued Increlex coverage.

Renewal Documentation Checklist

  • Growth velocity ≥2 cm/year (required for continued coverage)
  • Updated bone age x-ray confirming open epiphyses
  • Current IGF-1 levels and growth charts
  • Provider attestation of continued medical necessity
  • Safety monitoring compliance documentation

Timeline: Submit renewal 30-45 days before current authorization expires to avoid treatment gaps.

Specialty Pharmacy: Accredo Enrollment Process

Cigna requires Increlex to be dispensed through Accredo Specialty Pharmacy for most plans.

Enrollment Steps

  1. Provider Completes Referral Form
    • Download Accredo referral form
    • Include patient demographics, insurance information, and prescription details
    • Fax completed form to 888.302.1028
  2. Patient Enrollment Call
    • Accredo contacts patient within 24-48 hours
    • Verify insurance and shipping information
    • Schedule delivery and injection training
  3. Ongoing Support
    • 24/7 pharmacist support: 877.826.7657
    • Online portal: MyAccredoPatients.com
    • Refill reminders and adherence monitoring

Delivery: Temperature-controlled shipping at no additional cost, typically within 3-5 business days.

Common Problems and Solutions

Problem: Prior authorization taking longer than expected Solution: Contact Cigna at 866.494.2111 to check status and request expedited review if medically urgent

Problem: Accredo enrollment delayed Solution: Verify all insurance information is current and complete; call 877.826.7657 for status update

Problem: Hypoglycemia monitoring requirements unclear Solution: Review FDA prescribing information and work with your endocrinologist to develop a detailed monitoring plan

Problem: High out-of-pocket costs Solution: Contact Accredo financial counselors to explore manufacturer assistance programs and foundation grants

Frequently Asked Questions

How long does Cigna prior authorization take for Increlex in New York? Standard review is 1-2 business days with complete documentation. Expedited review is available within 24 hours for urgent medical situations.

What if Increlex is not on my Cigna formulary? You can request a formulary exception with clinical justification from your provider. Approval may take 1-2 business days for standard review.

Can I request an expedited appeal in New York? Yes, both Cigna internal appeals and New York DFS external appeals offer expedited review for urgent medical situations, with decisions in 24-72 hours.

Does step therapy apply if my child failed treatments in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Provide complete medical records from previous providers.

What happens if my Cigna appeal is denied? You can file for external review through the New York Department of Financial Services within 4 months. This independent review overturns approximately 50% of specialty drug denials.

How do I find a pediatric endocrinologist who prescribes Increlex? Use Cigna's provider directory and look for specialists with experience treating growth disorders and IGF-1 deficiency.

Counterforce Health helps patients navigate complex prior authorization and appeal processes for specialty medications like Increlex. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to individual payer policies. By turning insurance denials into targeted rebuttals with the right clinical documentation and medical literature, Counterforce Health helps patients get the treatments they need while reducing administrative burden on healthcare providers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Coverage policies and procedures may vary by plan and change over time. For assistance with insurance appeals and prior authorization, visit Counterforce Health or contact New York's Consumer Assistance Program at 888-614-5400.

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