Increlex (mecasermin) — CareFirst (Caremark)
Severe primary insulin-like growth factor-1 (IGF-1) deficiency
Initial criteria
- Age ≥ 2 years (pediatric patient)
- Pretreatment height ≥ 3 standard deviations (SD) below the mean for age and gender
- Pretreatment basal IGF-1 level ≥ 3 SD below the mean for age and gender
- Pediatric GH deficiency ruled out with a provocative GH test (peak GH level ≥ 10 ng/mL)
- Epiphyses are open
Reauthorization criteria
- The member’s growth rate > 2 cm/year OR documented clinical reason for lack of efficacy (e.g., on treatment less than 1 year, nearing final adult height/late stages of puberty)
- Epiphyses are open (confirmed by X-ray or X-ray is not available)
Approval duration
12 months