Increlex (mecasermin [rDNA origin] subcutaneous injection - Ipsen) — Cigna

Initial criteria

• Patient is ≥ 2 years of age; AND
• The epiphyses are open; AND
• Height standard deviation score is ≤ -3.0 at baseline; AND
• Basal IGF-1 standard deviation score is ≤ -3.0 at baseline; AND
• Growth hormone concentration is normal or increased at baseline; AND
• Patient will not be receiving concurrent treatment with growth hormone; AND
• Medication is prescribed by or in consultation with a pediatric endocrinologist

Reauthorization criteria

• Patient’s height has increased by ≥ 2 cm/year in the most recent year; AND
• The epiphyses are open; AND
• Patient will not be receiving concurrent treatment with growth hormone

Approval duration

1 year