CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Repository corticotropin injection (Acthar Gel, Cortrophin Gel) coverage criteria

Defines medical benefit coverage and prior authorization requirements for repository corticotropin injection (Acthar Gel and Cortrophin Gel) for Medicaid and Commercial members of Neighborhood Health Plan of Rhode Island; Medicare coverage applies only in absence of NCD/LCD.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRepository corticotropin injection (Acthar Gel, Cortrophin Gel) coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prospective prior authorization; initial coverage limited to 1 month.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Infantile spasmsFDA indication covered

1 monthInitial coverage

<=75 u/m² BID 2 wksDose limit

J0801, J0802Billing codes

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Infantile Spasms

Covered for Infantile Spasms when ALL of the following are met:

Diagnosis: Clinical documentation indicating member has a diagnosis of Infantile Spasms (West Syndrome)

Age: Member is less than 24 months old<24 months

Monotherapy: Must be used as monotherapy

Infection exclusion: Documentation that member does not have a suspected congenital infection

Acthar-specific requirement: If the request is for Acthar Gel, the member must have a documented contraindication, inadequate response or intolerance to Cortrophin Gel

Step requirement

Dose limit: Dose does not exceed 75 units/m² intramuscularly given twice daily for 2 weeks, then taper the dose over a 2-week period (e.g., 30 units/m² in the morning for 3 days; 15 units/m² in the morning for 3 days; 10 units/m² in the morning for 3 days; and 10 units/m² every other morning for 6 days)<=75 units/m² twice daily for 2 weeks

Taper schedule example provided in policy

Therapies used at a dose or for a condition other than those recognized as medically accepted indications in standard compendia are considered investigational and not covered. Neighborhood defines recognized indications by authoritative references such as AHFS‑DI, Micromedex DrugDex, Clinical Pharmacology, Lexi‑Drugs, or peer‑reviewed literature; if the requested use is outside those sources, coverage will not be provided.

Provider Actions and Requirements

Prior Authorization

Prior authorization required

Repository corticotropin injection (Acthar Gel or Cortrophin Gel) requires prospective prior authorization under the medical benefit. Initial authorization is granted for 1 month.

Applies to Medical Benefit; Medicare applies only in absence of NCD/LCD.

Step Therapy

Step through Cortrophin Gel before Acthar Gel

Requests for Acthar Gel must document a contraindication, inadequate response, or intolerance to Cortrophin Gel before coverage will be approved (step therapy requirement).

This requirement is part of the Infantile Spasms coverage criteria when the request is for Acthar Gel.

Documentation Required

Required clinical documentation for infantile spasms

Clinical documentation must show a diagnosis of Infantile Spasms (West Syndrome), that the member is less than 24 months old, and that therapy is being used as monotherapy; documentation must also show the member does not have a suspected congenital infection.

If requesting Acthar Gel, also include documentation of contraindication, inadequate response, or intolerance to Cortrophin Gel.
Dose limits and taper schedule must be documented (≤75 units/m² IM twice daily for 2 weeks, then taper per policy example).

Denial Risk

Noncompliant use may be denied

Use of repository corticotropin injection outside the stated guidelines may result in non-payment unless an exception is approved; coverage is reviewed prospectively via prior authorization.

Requests that do not meet prior authorization criteria may be denied.

Background

Acthar (repository corticotropin injection) and Cortrophin Gel are formulations of adrenocorticotropic hormone indicated for the treatment of infantile spasms in children under age 2 and have been reviewed by the plan’s Pharmacy & Therapeutics Committee to align coverage with FDA labeling and relevant literature. The policy requires documentation of diagnosis (Infantile Spasms/West Syndrome), age <24 months, use as monotherapy, exclusion of suspected congenital infection, and dosing limits (dose not to exceed 75 units/m² intramuscularly twice daily for 2 weeks with taper per the policy). Prior authorization is required and initial coverage is limited to 1 month; if Acthar Gel is requested the member must have a documented contraindication, inadequate response, or intolerance to Cortrophin Gel.