By Counterforce Health Team in Increlex (mecasermin) —

How to Get Increlex (mecasermin) Covered by UnitedHealthcare in Washington: Prior Authorization, Appeals & Step Therapy Exceptions

Answer Box: Getting Increlex Covered by UnitedHealthcare in Washington

UnitedHealthcare requires prior authorization for Increlex (mecasermin) through OptumRx, with strict diagnostic criteria for severe primary IGF-1 deficiency. Your fastest path: (1) Have your pediatric endocrinologist submit a PA request with IGF-1 labs ≤ -3.0 SDS, growth hormone stimulation test results, and hypoglycemia monitoring plan through the UHC provider portal; (2) If denied, file an internal appeal within 180 days; (3) Request external review through Washington's Insurance Commissioner if needed. Start today by calling UnitedHealthcare member services at 1-866-633-2446 to confirm your specific formulary status and PA requirements.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. When Alternatives Make Sense
  4. Typical Formulary Alternatives
  5. Pros and Cons Overview
  6. Exception Strategy
  7. Switching Logistics
  8. Re-trying for Increlex Later
  9. Appeals Playbook for Washington
  10. Common Denial Reasons & Fixes
  11. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Mandatory PA through OptumRx UHC Provider Portal UHC PA Policy
Formulary Tier Specialty tier drug Member benefits summary OptumRx Formulary
Step Therapy GH therapy trial typically required PA criteria document UHC Growth Hormone Policy
Specialty Pharmacy Accredo, CVS Specialty, Walgreens only OptumRx restrictions OptumRx Specialty Network
Age Limits ≥2 years old FDA label requirements FDA Increlex Label
Diagnosis Codes ICD-10: E34.3 (short stature) Clinical documentation Medical coding standards
Appeals Deadline 180 days from denial Washington state law WA Insurance Code

Step-by-Step: Fastest Path to Approval

1. Confirm Diagnosis and Lab Requirements

Who does it: Pediatric endocrinologist
Documents needed: IGF-1 levels ≤ -3.0 SDS, growth hormone stimulation test, height measurements
Timeline: 1-2 weeks for lab results
Source: FDA Increlex prescribing information

2. Submit Prior Authorization Request

Who does it: Healthcare provider
How to submit: UnitedHealthcare provider portal or fax
Expected timeline: 72 hours for standard, 24 hours for urgent
Required elements: Medical necessity letter, hypoglycemia monitoring plan, prior therapy documentation

3. Arrange Specialty Pharmacy

Who does it: Provider and patient
Options: Accredo, CVS Specialty, Walgreens Specialty (OptumRx cannot dispense)
Timeline: 3-5 business days after approval
Note: Set up glucose monitoring supplies before starting therapy

4. Monitor for Approval Decision

Who does it: Patient/caregiver
How: Check UHC member portal or call member services
Timeline: Decision within 72 hours for standard requests

Clinician Corner: Medical Necessity Letter Checklist

Your endocrinologist's PA request should include:Problem: Severe primary IGF-1 deficiency with specific lab values and growth measurementsPrior treatments: Documentation of any growth hormone therapy trials and outcomesClinical rationale: Why Increlex is medically necessary based on FDA-approved indicationsSafety plan: Detailed hypoglycemia monitoring protocol with glucose meter accessGuideline citations: Reference to FDA prescribing information and pediatric endocrine society guidelines

When Alternatives Make Sense

UnitedHealthcare typically requires attempting growth hormone therapy before approving Increlex, but alternatives may be appropriate when:

  • Growth hormone deficiency is the underlying cause (not severe primary IGF-1 deficiency)
  • Secondary IGF-1 deficiency due to malnutrition, hypothyroidism, or other correctable causes
  • Cost considerations when diagnostic criteria for Increlex aren't clearly met
  • Safety concerns about hypoglycemia risk in very young children

However, if your child has confirmed severe primary IGF-1 deficiency with normal or elevated growth hormone levels, alternatives are unlikely to be effective, and you should pursue an exception to step therapy requirements.

Typical Formulary Alternatives

Growth Hormone Products (Step Therapy Requirement)

  • Genotropin (somatropin): Typically first-line for growth hormone deficiency
  • Humatrope (somatropin): Alternative GH option with similar efficacy
  • Norditropin (somatropin): Pen delivery system for easier administration

Nutritional Management

  • High-calorie supplements: For secondary IGF-1 deficiency due to malnutrition
  • Specialized formulas: When underlying metabolic conditions contribute to growth failure
Note: These alternatives address different underlying causes than severe primary IGF-1 deficiency. If your child has SPIGFD with normal GH levels, growth hormone therapy will not be effective.

Pros and Cons Overview

Consideration Growth Hormone Therapy Increlex (mecasermin)
Access Usually covered first-line Requires PA and often step therapy
Administration Daily injection Twice daily with meals
Monitoring Routine growth tracking Intensive glucose monitoring required
Effectiveness Effective for GH deficiency Only effective for primary IGF-1 deficiency
Cost Lower tier, better coverage Specialty tier, ~$16,000/month retail
Safety Profile Well-established Hypoglycemia risk requires careful monitoring

Exception Strategy

When to Request Step Therapy Exception

Request an exception when your child has:

  • Confirmed severe primary IGF-1 deficiency with normal or elevated GH levels
  • GH gene deletion with neutralizing antibodies to growth hormone
  • Previous growth hormone therapy failure with documented lack of response

Evidence That Helps Exception Requests

  1. Comprehensive lab work: IGF-1 levels, GH stimulation test results with reference ranges
  2. Growth velocity data: Documented poor growth despite adequate nutrition
  3. Prior therapy records: If GH was tried, include duration, dosing, and growth response
  4. Specialist consultation: Letter from pediatric endocrinologist explaining why Increlex is specifically indicated
  5. Safety monitoring plan: Detailed protocol for hypoglycemia prevention and management

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to draft point-by-point rebuttals aligned with the insurer's own rules.

Switching Logistics

Provider Coordination

  • Schedule follow-up with endocrinologist to discuss alternative therapy options
  • Request medical records transfer if switching to a different specialist
  • Ensure continuous monitoring during any therapy transition

Pharmacy Coordination

  • Confirm formulary status of alternative medications
  • Arrange specialty pharmacy services if needed for growth hormone products
  • Verify insurance coverage and copay responsibilities before starting

Documentation During Trial Period

  • Track growth velocity, side effects, and lab changes
  • Maintain detailed records of therapy adherence and any challenges
  • Document reasons for therapy failure if planning to re-request Increlex

Re-trying for Increlex Later

What to Document During Alternative Therapy

  • Growth response: Measure height velocity every 3-6 months
  • Lab monitoring: Track IGF-1 levels and other relevant markers
  • Side effects: Document any adverse reactions or tolerability issues
  • Adherence: Record compliance with therapy and any barriers

Strengthening Your Case for Re-appeal

  • Therapy failure documentation: Clear evidence that alternatives didn't achieve growth goals
  • Updated labs: Recent IGF-1 levels confirming continued deficiency
  • Clinical deterioration: Any worsening of growth parameters
  • New evidence: Updated guidelines or studies supporting Increlex use
From Our Advocates: We've seen families successfully obtain Increlex approval after initial denials by working closely with their endocrinologist to document inadequate response to growth hormone therapy over 6-12 months. The key was maintaining detailed growth charts and lab tracking that clearly showed continued severe IGF-1 deficiency despite optimal GH treatment. This is a composite example and outcomes vary by individual case.

Appeals Playbook for Washington

Internal Appeals (UnitedHealthcare)

  • Deadline: 180 days from denial date
  • How to file: UHC member portal, phone, or written request
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Denial letter, medical records, physician support letter

External Review (Washington State)

  • When available: After exhausting internal appeals
  • How to request: Through Washington Insurance Commissioner or directly with UHC
  • Timeline: 15 days for standard, 72 hours for expedited
  • Contact: Washington Insurance Commissioner at 1-800-562-6900
  • Success rate: Approximately 50% for specialty medications with comprehensive documentation

Expedited Appeals

Request expedited review when:

  • Treatment delay could seriously jeopardize health
  • Child's growth is significantly compromised
  • Current therapy is causing adverse effects

Common Denial Reasons & Fixes

Denial Reason How to Overturn
"Not medically necessary" Submit updated medical necessity letter with specific diagnostic criteria and lab values
"Step therapy not completed" Request exception with documentation of GH therapy contraindication or failure
"Missing documentation" Provide complete lab results, growth charts, and specialist consultation notes
"Age restriction" Confirm patient is ≥2 years old with birth certificate if needed
"Safety concerns" Submit detailed hypoglycemia monitoring plan and glucose meter access confirmation

FAQ

How long does UnitedHealthcare PA take in Washington? Standard prior authorization decisions are made within 72 hours, with urgent requests processed within 24 hours.

What if Increlex is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Non-formulary doesn't mean automatic denial if medically necessary.

Can I request an expedited appeal? Yes, if treatment delay could seriously impact your child's health or development. Expedited appeals receive decisions within 72 hours.

Does step therapy apply if we've tried GH therapy outside Washington? Previous therapy documentation from other states is typically accepted. Provide complete medical records showing therapy trial and outcomes.

What's the cost without insurance coverage? Increlex retails for approximately $16,000 per 4 mL vial. Manufacturer assistance programs may be available through Ipsen Cares.

How do I file a complaint with Washington state? Contact the Washington Insurance Commissioner at 1-800-562-6900 if you believe UnitedHealthcare improperly denied coverage.

What happens if the external review upholds the denial? External review decisions are binding on UnitedHealthcare. If upheld, you may need to pursue legal options or continue with alternative therapies.

Can I switch specialty pharmacies once approved? Yes, but confirm the new pharmacy is in UnitedHealthcare's specialty network (Accredo, CVS Specialty, or Walgreens Specialty only).

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and procedures may change.

For additional help navigating insurance appeals in Washington, contact the Washington State Office of the Insurance Commissioner Consumer Advocacy team at 1-800-562-6900.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify denial reasons and draft point-by-point rebuttals aligned with the insurer's own coverage rules.

Sources & Further Reading

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