Repository corticotropin injection (Acthar)

Acthar Gel is covered only for the FDA‑approved indication of infantile spasms (West syndrome) in infants/children under 2 years, while other indications are not automatically covered and require medical director review. Coverage requires the patient be <2 years with documented diagnosis and age, prescribed by a physician who has consulted with or specializes in neurology, is limited to one month of approval, and should follow the policy’s recommended dosing/tapering.

"Infantile spasms (West syndrome) in infants and children under 2 years of age (FDA‑approved indication)."

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