CurrentAetnaPolicy N/A

Precertification request form for Acthar Gel and Purified Cortrophin Gel

Form and instructions required for providers to request precertification for Acthar Gel (repository corticotropin) or Purified Cortrophin Gel injectable therapy for Aetna members; applies to providers submitting authorization requests in North Carolina.

Policy Summary

PayerAetna

PolicyPrecertification request form for Acthar Gel and Purified Cortrophin Gel

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrecertification must be requested using this form and include complete clinical information, diagnosis codes, and prior treatment dates as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1primary product choices on form (Acthar Gel, Purified Cortrophin Gel)

Requiredclinical information required for all requests

Phone/FaxAetna contact lines provided

Includedpatient, insurance, and prescriber sections included

Coverage and Form Requirements

Policy Summary

PayerAetna

PolicyPrecertification request form for Acthar Gel and Purified Cortrophin Gel

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrecertification must be requested using this form and include complete clinical information, diagnosis codes, and prior treatment dates as applicable.

SourceLink

On This Page

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Form completion: All required form fields (patient information, insurance, prescriber, dispensing provider/administration, product selection, and clinical information) are completed and legible for precertification review.

See sections A–H on the precertification form; start/continuation checkbox and signature required.

Product selection: Request is for Acthar Gel OR Purified Cortrophin Gel.

Form contains explicit checkboxes for product choice and dose/frequency fields.

Indication and clinical documentation: Required clinical information must be completed in its entirety for all requests; include primary (and secondary if applicable) diagnosis codes and supporting clinical documentation.

Clinical information section G is mandatory for initiation and continuation requests.

Coverage consideration is initiated when the precertification form is completed and legible. All required form fields — including patient information, insurance details, prescriber information, dispensing provider/administration details, product selection (Acthar Gel or Purified Cortrophin Gel), and the clinical information section — must be provided for review. The form includes distinct sections for initiation versus continuation requests and prompts for indication-specific details such as infantile spasms and prior treatment dates.

Submission, Documentation, and Risk Notices

Prior Authorization

Precertification submission

Precertification must be requested using the Acthar Gel / Purified Cortrophin Gel Injectable Medication Precertification Request form. Complete and legible submission is required for review. Aetna precertification contact numbers for submission and inquiries: Phone 1-866-752-7021; Fax 1-888-267-3277. For Medicare Advantage Part B submissions, Phone 1-866-503-0857; Fax 1-844-268-7263.

Use the specified form for both start-of-treatment and continuation requests.
Include precertification requester name, phone, and fax on the form.

Documentation Required

Indication and benefit documentation

Indication and benefit documentation must be provided on the form. The form asks whether Acthar Gel is being initiated for infantile spasms in patients <2 years and whether the patient has shown substantial clinical benefit for continuation requests. Include dates of any prior Acthar or corticotropin treatments.

Indicate if Acthar Gel will be used in combination with Purified Cortrophin Gel.
For initiation: confirm if indication is infantile spasms in a patient <2 years.
For continuation: document substantial clinical benefit and list prior treatment dates.

Documentation Required

Required documentation

Complete clinical information is required for all requests. Provide patient demographics (name, DOB, contact information, weight, height, allergies), diagnosis ICD codes, prescriber information (name, specialty, NPI, license, contact), and treatment plan details per the form.

Patient information: full name, DOB, address, phone(s), weight, height, allergies, email.
Prescriber information: name, credential (MD/DO/NP/PA), specialty (e.g., neurologist, pediatrician), NPI, state license, DEA (if applicable), phone and fax.
Clinical fields: indication, prior treatment dates, combination therapy status, and for continuation requests — documentation of substantial clinical benefit.

Denial Risk

Incomplete or fraudulent submissions

Failure to provide complete, legible, and truthful information may result in denial of the request and may be considered fraud. The request form requires a signature certifying the accuracy of the information. Aetna may request additional information or clarification as needed to evaluate requests.

Do not submit incomplete or illegible forms — incomplete submissions may be denied.
Knowingly providing false or concealed material information may subject the filer to criminal and civil penalties.
Signature and date are required on the acknowledgment section of the form.

Policy Background

This precertification request form is used to request authorization for repository corticotropin products — specifically Acthar Gel and Purified Cortrophin Gel. The form captures whether the request is for initiation or continuation of therapy, product selection, place of administration, and required clinical documentation. For initiation requests the form specifically asks whether therapy is being started for infantile spasms in patients under 2 years. For continuation requests the form requires documentation of prior treatment dates and confirmation that the patient has demonstrated substantial clinical benefit from therapy. Aetna precertification contact numbers are provided on the form for submission and inquiries.

Key Request Types

inv-11: Start of treatment indicated on form with start date required — Initiation request

DefinitionInitiation request: Start of treatment indicated on form with start date required.

Form fieldInitiation-specific checkbox: 'Is Acthar Gel being initiated for infantile spasms in a patient who is less than 2 years old?' (Yes/No).

Required documentationFor initiation, clinical information must be completed in its entirety on the form.

Product selectionRequest must specify product (Acthar Gel or Purified Cortrophin Gel) on the product information section.

inv-12: Continuation requires documentation of substantial clinical benefit and prior treatment dates — Continuation request

DefinitionContinuation request: Requires documentation that the patient has shown substantial clinical benefit and includes dates of previous treatments.

Form fieldContinuation-specific checkbox: 'Has the patient shown substantial clinical benefit from therapy?' (Yes/No).

Required datesForm requests the dates of previous treatments to be provided for continuation requests.

Documentation requirementClinical information for continuation must be completed in its entirety on the form.

Initial Therapy Requirements

Initial therapy requirements

Initiation requests require indication documentation and specify an infantile spasms prompt.

Initiation: If initiating therapy, provider must indicate whether Acthar Gel is being initiated for infantile spasms in a patient less than 2 years old, provide the start date, and supply supporting clinical documentation.

Form includes a checkbox asking specifically about infantile spasms for patients <2 years and a start date field.

Continuation Therapy Requirements

Continuation therapy requirements

Continuation requests must document ongoing benefit and prior therapy dates.

Continuation documentation: For continuation requests, provider must confirm the patient has shown substantial clinical benefit from therapy and provide dates of previous treatments.

Form continuation checkbox and fields for dates of previous treatments are required.

Primary ICD Code	Primary diagnosis ICD code requested on form
Secondary ICD Code	Secondary diagnosis ICD code (If applicable) requested on form

Question	Response options	Provider action / documentation required
Will Acthar Gel be used in combination with Purified Cortrophin Gel?
No; Yes
Form requires provider to indicate Yes or No; if combination therapy is planned, supporting clinical documentation should be provided as part of the precertification request.

OpenPayer