Acthar Gel (repository corticotropin injection)

Acthar Gel is covered only as monotherapy for infantile spasms (West syndrome) in infants/children under 2 years; other indications are not automatically covered and require medical director review. Approval is limited to one month and requires documentation of diagnosis and age, prescribing by or consultation with a neurologist, adherence to the dosing/taper (150 U/m2 total: 75 U/m2 IM twice daily for 2 weeks with a gradual 2‑week taper), and meeting the referenced coverage/safety criteria.

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

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