Acthar® Gel (repository corticotropin injection)

Covered only for infantile spasms as Acthar Gel monotherapy in infants/children under 2 years when given intramuscularly and prescribed by or after consultation with a neurology specialist; other FDA indications are excluded unless reviewed/approved by a medical director. Approval is limited to 1 month with recommended dosing 150 U/m^2 total (75 U/m^2 IM twice daily) and a taper after 2 weeks, and requires documentation of diagnosis, age <2, IM administration, neurology consult/specialty, and dosing/taper plan.

"Route restriction: Acthar Gel must be administered as an intramuscular injection."

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