Payer PolicyActive
Repository corticotropin injection (Purified Cortrophin Gel)
EVICORE-MEDICAL_DRUG-EF92713D
EviCore by Evernorth
Effective: March 1, 2023
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Purified corticotropin gel is limited to FDA‑approved indications (rheumatic, collagen, dermatologic, allergic, ophthalmic, respiratory, edematous, and nervous system disorders) but approval is not recommended due to insufficient updated efficacy data and potential long‑term safety concerns; requests must document an FDA‑approved diagnosis and meet the specific coverage guidelines.
Coverage Criteria Preview
Key requirements from the full policy
"When requesting Purified Cortrophin Gel (repository corticotropin injection), the individual requiring treatment must be diagnosed with a FDA-approved indication and meet the specific coverage guid..."
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