Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Repository corticotropin injection (Acthar Gel) may be considered medically necessary for use in individuals who meet the following criteria:
- The individual has a diagnosis of infantile spasms; and
- The individual is less than 24 months of age; and
- The individual does NOT have any FDA labeled contraindications to repository corticotropin injection (Acthar Gel); and
- The requested quantity (dose) is within FDA labeled dosing for repository corticotropin injection (Acthar Gel).
Repository corticotropin injection (Acthar Gel) is considered not medically necessary for any other indication.