Acthar® Gel (repository corticotropin injection)

Coverage is limited to Acthar Gel for infantile spasms in infants <2 years given intramuscularly; patients ≥2 years and other indications are excluded (other FDA‑approved uses require medical director review). Approval is for 1 month with required dosing of 150 U/m^2 total (75 U/m^2 IM twice daily) with a gradual taper after 2 weeks, and documentation must confirm diagnosis, age, IM route, neurologist consultation/prescriber, dosing/taper plan, and applicable safety criteria.

"Acthar Gel is prescribed by a physician who has consulted with or specializes in neurology."

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