Corticotropin prior authorization (Acthar Gel, Cortrophin)
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Defines prior authorization (PA) requirements and approvable indications for repository corticotropin injections (Acthar Gel and Purified Cortrophin Gel) for Georgia Medicaid fee-for-service members.
No material clinical or coverage changes in this revision.
Covered Indications & Criteria
inv-01: Appropriate Use — Selected Diagnoses and Conditions
Approvals for Acthar and Cortrophin; covered when the following age- and condition-specific rules are met
No PA required per policy for this group.
Specifies recent inadequate response or corticosteroid contraindication/intolerance.
Requires failure/intolerance to specified biologics and corticosteroid issues.
Requires failure/intolerance to antimalarials and corticosteroid issues.
inv-02: Other Covered Indications (>=2 years unless noted)
Additional approvable inflammatory and ophthalmologic/nephrologic conditions
Requires recent inadequate response or corticosteroid contraindication/intolerance.
Per policy, members under 2 years of age with a diagnosis of infantile spasms (West Syndrome) do not require prior authorization for Acthar Gel or Purified Cortrophin Gel. This is an explicit age-based exception and should be applied when the submitted claim or request documents infantile spasms in a patient younger than 2 years.
For all other indications and age groups, prior authorization is required and approvals are determined according to the condition-specific clinical criteria and step-therapy requirements in the policy.
Initial Therapy Rules
inv-10: Initial therapy rules
Initial approval conditions
Prior Therapy (Step) Requirements
| Requirement | Details / Examples |
|---|---|
| Prior failure, intolerance, or contraindication to specified agents | |
| • For MS exacerbations (age ≥18): inadequate response within last 30 days, or contraindication/intolerance to high‑dose IV methylprednisolone or high‑dose oral corticosteroid; for relapsing‑remitting MS the member must be on an immunomodulator for ≥3 months. |
Prior Authorization, How to Request, and Billing
Prior authorization required except infantile spasms <2 years
Prior authorization is required for Acthar Gel and Purified Cortrophin Gel for all uses except members under 2 years with a diagnosis of infantile spasms (West Syndrome); approvals are granted when the member meets the listed diagnosis-specific criteria (age thresholds and required prior therapy failure, recent inadequate response, or contraindication/intolerance to high‑dose corticosteroids or specified agents).
- Exemption: No PA required for members <2 years with infantile spasms (West Syndrome).
- Approvals require meeting the policy’s disease‑specific criteria including prior therapy failure/inadequate response or corticosteroid contraindication/intolerance as detailed in the coverage criteria.
Document prior therapy failures or contraindications per indication
Obtain documentation of prior inadequate response, intolerance, or contraindication to specified first‑line therapies before PA will be approved — e.g., inadequate response within the last 30 days or prior trials as specified (such as 3 months for certain biologic agents like Enbrel or Humira; hydroxychloroquine/chloroquine for lupus; or failure/intolerance to high‑dose IV/oral corticosteroids).
- For MS exacerbations: recent inadequate response within 30 days or contraindication/intolerance to high‑dose IV methylprednisolone or high‑dose oral corticosteroid; relapsing‑remitting MS must be on an immunomodulator ≥3 months.
- For inflammatory arthritides: inadequate response after 3 months to Enbrel and Humira and recent inadequate response or corticosteroid contraindication/intolerance.
- For SLE: prior trial of hydroxychloroquine/chloroquine with inadequate response and recent inadequate response or corticosteroid contraindication/intolerance.
How to request PA and billing note
Initiate the prior authorization process by calling OptumRx at 1-866-525-5827 or use the online PA Request Process Guide at www.dch.georgia.gov/priorauthorization-process-and-criteria; if the medication is administered in a physician’s office or clinic, bill through the DCH physician’s injectable program (not the outpatient pharmacy program).
- Phone PA initiation: OptumRx 1-866-525-5827.
- Online PA: DCH Prior Authorization Request Process Guide at www.dch.georgia.gov/priorauthorization-process-and-criteria.
- Billing: physician‑administered doses must be billed via the DCH physician’s injectable program (see www.mmis.georgia.gov).
PA process required for exceptions — lack of PA may lead to denial
Exceptions to the coverage conditions are adjudicated through the prior authorization process; failure to obtain PA for non‑exempt uses may result in denial of coverage.
- All exception requests must go through the PA process (contact OptumRx).
Quantity Limits and Product References
Administration & Billing Site Rules
Office administration — bill through DCH physician's injectable program
If repository corticotropin is administered in a physician's office or clinic, the provider must bill the medication through the DCH physician's injectable program rather than the outpatient pharmacy program; program information is available at www.mmis.georgia.gov.
- This billing requirement applies when the medication is administered in an office/clinic setting.
Key Definitions
Clinical Background
Repository corticotropin injections (Acthar Gel and Purified Cortrophin Gel) are included in the DCH corticotropin PA program and are subject to the program’s prior authorization processes and billing rules. Providers should note that when these agents are administered in a physician’s office or clinic, they must be billed through the DCH physician’s injectable program rather than the outpatient pharmacy program; details and program information are available at www.mmis.georgia.gov.
Prior authorization exceptions (such as the infantile spasms under age 2 exception) are specified in the policy, and non-exempt uses require PA before coverage will be approved.
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