I Affirm That the Information Given on This Form Is True and Accurate As of This Date

Prescriber Fax Form
MediGold
Increlex(mecasermin)
(Coverage Determination)
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Complete/review information, sign and date. Fax signed forms to CVS/Caremark at 1-855-633-7673.
Please contact CVS/Caremark at 1-866-785-5714 with questions regarding the prior authorization process.When conditions are met, we will authorize the coverage of Increlex(mecasermin) (Coverage Determination).
Drug Name:
Increlex(mecasermin)
Patient Information
Patient Name:
Patient ID:
Patient Group No.:
Patient DOB:
Patient Phone:
Prescribing Physician
Physician Name:
Physician Phone:
Physician Fax:
Physician Address:
City, State, Zip:
Diagnosis: / ICD Code:
Please circle the appropriate answer for each question.
Does the patient have a diagnosis of severe primary insulin-like growth factor-1 (IGF-1) deficiency or growth hormone (GH) gene deletion with neutralizing antibodies to GH?
[If no, no further questions.] / Yes / No
Does the patient have closed epiphyses?
[If yes, no further questions.] / Yes / No
Is the patient currently undergoing treatment with Increlex therapy?
[If yes, skip to question 7.] / Yes / No
Is the patient’s height 3 or more standard deviations below the norm for children of the same age and gender?
[If no, no further questions.] / Yes / No
Does the patient have a basal IGF-1 level 3 or more standard deviations below the norm for children of the same age and gender?
[If no, no further questions.] / Yes / No
Did the patient have a stimulation test showing a normal or elevated GH level?
[If yes, skip to question 9.]
[If no, no further questions.] / Yes / No
Is the patient growing more than 2 cm/year?
[If no, no further questions.] / Yes / No
Does the patient have a current IGF-1 level that is normal for age and gender?
[If no, no further questions.] / Yes / No
Is Increlex being prescribed by or in consultation with an endocrinologist? / Yes / No
Comments:

I affirm that the information given on this form is true and accurate as of this date.

Prescriber (Or Authorized) Signature and Date