Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel)

Aetna covers repository corticotropin injection (Acthar Gel only) for infantile spasms in children <2 years (and continuation if substantial clinical benefit) with HCPCS J0801/J0802 and ICD-10 G40.821–G40.824 when selection criteria are met, and precertification is required for Acthar Gel or Purified Cortrophin Gel in applicable plan designs. Aetna considers Acthar Gel and Purified Cortrophin Gel not medically necessary for acute MS exacerbations in adults (despite a listed 80–120 unit/day ×2–3 weeks regimen), for specified rheumatic disorders (psoriatic arthritis, RA including juvenile RA, ankylosing spondylitis, acute gout), selected collagen diseases (SLE, dermatomyositis/polymyositis), and severe dermatologic diseases (erythema multiforme, Stevens–Johnson syndrome, severe psoriasis).

"Aetna considers repository corticotropin injection (Acthar Gel only) medically necessary for treatment of infantile spasms in members who are less than 2 years of age."