By Counterforce Health Team in Increlex (mecasermin) —

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

Answer Box: Getting Increlex Covered by UnitedHealthcare in Illinois

To get Increlex (mecasermin) covered by UnitedHealthcare in Illinois: Submit prior authorization through OptumRx with documented severe primary IGF-1 deficiency (height ≤-3 SD, IGF-1 below 5th percentile, normal/elevated GH levels) from a pediatric endocrinologist. If denied, file internal appeal within 180 days, then Illinois external review within 4 months. Start today: Gather IGF-1 labs, growth charts, and GH stimulation test results, then call UnitedHealthcare at 1-877-842-3210 to initiate prior authorization.

Table of Contents

  1. Why Illinois State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. Illinois Turnaround Standards
  4. Step Therapy Protections in Illinois
  5. Appeals Process: Internal to External Review
  6. Common Denial Reasons & How to Fix Them
  7. Costs and Patient Assistance Options
  8. When to Contact Illinois Regulators
  9. FAQ

Why Illinois State Rules Matter

Illinois provides some of the strongest patient protections in the nation for insurance appeals. Under the Illinois Health Carrier External Review Act (215 ILCS 180), you have the right to an independent medical review by a board-certified physician if UnitedHealthcare denies Increlex after your internal appeal. This external review decision is binding on UnitedHealthcare—meaning they must cover the treatment if the independent reviewer finds it medically necessary.

Starting January 1, 2026, Illinois' Healthcare Protection Act also prohibits most step therapy requirements, which could eliminate barriers to Increlex coverage. However, prior authorization requirements remain in place for specialty medications like Increlex.

For UnitedHealthcare members in Illinois, these state protections work alongside federal requirements to create multiple pathways for overturning coverage denials.

UnitedHealthcare Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required through OptumRx UnitedHealthcare Provider Portal
Formulary Status Specialty tier (verify with plan) Member portal or call 1-877-842-3210
Prescriber Requirement Pediatric endocrinologist preferred Plan documents
Age Limit Typically pediatric use only FDA labeling requires growth plate closure monitoring
Diagnosis Documentation Severe primary IGF-1 deficiency ICD-10: E34.3 (Short stature due to endocrine disorder)

Medical Necessity Criteria

Based on standard payer policies for Increlex, UnitedHealthcare typically requires:

  • Height below -3.0 standard deviations for age and gender
  • IGF-1 levels consistently below the 5th percentile for age and gender (at least two measurements)
  • Normal or elevated growth hormone levels (ruling out GH deficiency)
  • Failed response to growth hormone therapy (if previously tried)
  • Prescription by pediatric endocrinologist with expertise in growth disorders
Clinician Corner: Your medical necessity letter should address each criterion explicitly. Include growth velocity data, bone age studies, and documentation of why growth hormone therapy is inappropriate or has failed. Reference the FDA prescribing information for dosing and monitoring requirements.

Illinois Turnaround Standards

Illinois law requires UnitedHealthcare to respond to prior authorization requests within specific timeframes:

Standard Prior Authorization

  • 72 hours for regular medication needs
  • 24 hours for urgent medication needs
  • If no response within these timeframes, the request is deemed approved

Internal Appeals

  • 15 business days for post-service appeals
  • 48 hours for expedited appeals (when delay would jeopardize health)
  • UnitedHealthcare must acknowledge receipt within 3 business days

These timelines are enforced by the Illinois Department of Insurance, and violations can result in regulatory action.

Step Therapy Protections in Illinois

Illinois' new Healthcare Protection Act (effective January 1, 2026) broadly prohibits step therapy requirements for most commercial health plans, including UnitedHealthcare. This means you shouldn't need to try and fail other treatments before accessing Increlex, provided it's medically appropriate.

Medical Exception Criteria (Pre-2026 or if Step Therapy Still Applies)

If step therapy requirements remain in your specific plan, you can request an exception if:

  • Alternative medications are contraindicated
  • You've previously failed alternative treatments
  • Alternative medications would cause adverse reactions
  • You're currently stable on Increlex (continuity of care)

Document these exceptions with clinical notes, lab results, and prescriber attestation.

Appeals Process: Internal to External Review

Step 1: Internal Appeal with UnitedHealthcare

Timeline: File within 180 days of denial notice

How to File:

Required Documents:

  • Denial letter or EOB
  • Medical records supporting medical necessity
  • Prescriber letter addressing denial reasons
  • Any additional clinical documentation

Step 2: Illinois External Review

If UnitedHealthcare upholds the denial, you can request an independent external review through the Illinois Department of Insurance.

Timeline: Within 4 months of final internal denial

How to File:

Review Process:

  • Independent physician reviewer with relevant expertise
  • Decision within 5 business days of receiving all materials
  • Binding decision—UnitedHealthcare must comply if approved
From Our Advocates: We've seen families successfully overturn Increlex denials by providing comprehensive growth data and demonstrating that the child meets FDA-approved criteria for severe primary IGF-1 deficiency. The key is thorough documentation of failed growth velocity despite adequate nutrition and ruling out other causes of growth failure.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not primary IGF-1 deficiency" Provide GH stimulation test results showing normal/elevated GH; rule out malnutrition, chronic disease
"Missing IGF-1 laboratory values" Submit at least two IGF-1 measurements below 5th percentile, drawn at different times
"No safety monitoring plan" Include hypoglycemia monitoring protocol, injection site rotation plan
"Quantity limits exceeded" Provide weight-based dosing calculations; reference FDA labeling for appropriate dose escalation
"Step therapy not completed" Cite Illinois Healthcare Protection Act (if applicable) or document GH therapy failure/contraindication

Costs and Patient Assistance Options

Increlex costs approximately $16,000 per 4 mL vial at retail cash prices. Patient assistance options include:

Manufacturer Support

  • Ipsen Patient Assistance Program: Contact Ipsen at 1-855-463-5127 for eligibility requirements
  • Copay assistance: May be available for commercially insured patients (verify current programs)

Illinois-Specific Resources

  • Illinois Department of Healthcare and Family Services: For Medicaid coverage questions (1-877-805-5312)
  • Illinois 211: Dial 2-1-1 for local assistance programs and resources

Foundation Support

  • National Organization for Rare Disorders (NORD): Rare disease patient assistance programs
  • HealthWell Foundation: May provide copay assistance for qualifying patients

When to Contact Illinois Regulators

Contact the Illinois Department of Insurance if:

  • UnitedHealthcare doesn't respond within required timeframes
  • You need help filing an external review
  • You believe UnitedHealthcare isn't following Illinois law

Illinois Department of Insurance Consumer Assistance:

  • Phone: 877-527-9431 (Office of Consumer Health Insurance)
  • Online: Submit a complaint
  • They provide free guidance on appeals and can intervene with insurers

Illinois Attorney General Health Care Bureau:

  • Helpline: 1-877-305-5145
  • Can assist with complex insurance disputes

For patients and clinicians navigating complex prior authorization and appeal processes, Counterforce Health helps turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

FAQ

How long does UnitedHealthcare prior authorization take for Increlex in Illinois? UnitedHealthcare must respond within 72 hours for standard requests or 24 hours for urgent requests under Illinois law. If they don't respond within these timeframes, the request is deemed approved.

What if Increlex is not on my UnitedHealthcare formulary? You can request a formulary exception through the prior authorization process. Provide medical necessity documentation showing why formulary alternatives are inappropriate for your specific condition.

Can I request an expedited appeal if my child needs Increlex urgently? Yes. If delay would jeopardize health or ability to regain function, you can request expedited internal appeal (48-hour decision) and expedited external review through Illinois DOI.

Does Illinois' step therapy ban apply to all UnitedHealthcare plans? The Healthcare Protection Act applies to most commercial plans but may not cover all plan types (such as self-funded employer plans governed by ERISA). Contact UnitedHealthcare or Illinois DOI to confirm your specific plan's requirements.

What happens if the Illinois external review approves Increlex coverage? The decision is binding on UnitedHealthcare. They must provide coverage according to the reviewer's determination and cannot appeal the decision.

How do I prove severe primary IGF-1 deficiency for Increlex coverage? Provide documentation of height below -3.0 standard deviations, IGF-1 levels below 5th percentile (multiple measurements), normal or elevated growth hormone levels, and evaluation by a pediatric endocrinologist ruling out other causes of growth failure.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Insurance coverage requirements and state laws can change. Always verify current requirements with UnitedHealthcare and consult with your healthcare provider about treatment decisions. For personalized assistance with insurance appeals, contact the Illinois Department of Insurance or consider working with Counterforce Health, which specializes in turning insurance denials into successful appeals through targeted, evidence-backed documentation.

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