Repository Corticotropin Injections – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers Acthar Gel and Purified Cortrophin Gel only for infantile spasms (West syndrome) in patients <2 years for up to 4 weeks (authorizations ≤1 month) and for opsoclonus‑myoclonus syndrome for up to 3 months, when there is a confirmed diagnosis, dosing per FDA labeling, and a provider attestation (with explanation) that the caregiver cannot be trained or is physically unable to administer. The drugs are not medically necessary for acute MS exacerbations under medical‑necessity plans (may be allowed under non‑medical‑necessity plans) and are considered unproven/not medically necessary for a long list of other rheumatic, dermatologic, collagen, allergic, ophthalmic, respiratory and edematous conditions and any other off‑label indications, with required documentation of diagnosis, patient age (for infantile spasms), FDA‑consistent dosing, and the caregiver attestation.

"Dosing documentation consistent with FDA approved labeling (dosing must be in accordance with FDA labeling)."