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New coverage criteria for repository corticotropin (H.P. Acthar® Gel Injection)

October 1, 2014

Effective November 25, 2014, Independence?s medical policy on repository corticotropin (H.P. Acthar® Gel Injection) will be updated to reflect new medical necessity coverage criteria. According to the new version of the policy, Independence will only approve the use of H.P. Acthar® Gel Injection when both of the following criteria are met:

  • The individual is diagnosed with West syndrome (infantile spasms).
  • The individual is age 2 or younger.

Independence will no longer consider H.P. Acthar® Gel Injection eligible for coverage for conditions that do not meet these criteria because the drug is considerably more costly than alternative conventional corticosteroid and/or immunosuppressive therapies that are at least as likely to produce equivalent results in the diagnosis or treatment of the individual?s illness, injury, or disease. Therefore, as of November 25, 2014, Independence will no longer approve requests for H.P. Acthar® Gel Injection for uses such as, but not limited to, the following:

  • multiple sclerosis;
  • rheumatic disorders (e.g., psoriatic arthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis);
  • collagen diseases (e.g., systemic lupus erythematosus, systemic dermatomyositis [polymyositis]);
  • dermatologic disease (e.g., severe erythema multiforme, Stevens-Johnson syndrome);
  • allergic states (e.g., serum sickness);
  • ophthalmic diseases (e.g., keratitis, iritis, iridocyclitis, diffuse posterior uveitis, choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation);
  • respiratory conditions (e.g., symptomatic sarcoidosis);
  • to induce a diuresis or a remission of proteinuria in nephrotic syndrome without uremia of the idiopathic type or due to lupus erythematosus;
  • corticosteroid-responsive conditions;
  • diagnostic testing for adrenocortical function.

Physicians can review the Notification for Medical Policy #08.01.12a: Repository Corticotropin (H.P. Acthar® Gel Injection) by going to our Medical Policy Portal, selecting Accept and Go to Medical Policy Online, and then typing the policy name or number in the Search box.


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