Repository corticotropin injection (Acthar)

Acthar Gel is covered only as monotherapy for FDA‑approved infantile spasms (West syndrome) in patients under 2 years; all other indications require medical director review (not routinely approved). Approval is for 1 month and requires documentation of diagnosis and age <2, evidence the prescriber consulted with or is a neurologist, and a prescribed dosing/taper plan of 150 U/m2 total (75 U/m2 twice daily) with taper after 2 weeks.

"Approval duration: 1 month."

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