CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Corticotropin - ACTH (Acthar Gel / Cortrophin Gel) coverage

Governs medical benefit coverage and prior authorization criteria for repository corticotropin injection (Acthar Gel and Cortrophin Gel) for Medicaid and Commercial members; excludes Medicare-Medicaid Plan (MMP) Part B coverage effective 10/01/2023.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCorticotropin - ACTH (Acthar Gel / Cortrophin Gel) coverage

Policy CodePolicy N/A

Change TypeCoverage limitation added for MMP Part B

Effective DateJan 1, 2020

Next Review DateJan 10, 2024

Key ActionSubmit prior authorization with clinical documentation of diagnosis and indication-specific criteria, including age <24 months and dosing within specified limits.

SourceLink

POLICY UPDATE CHANGES

Effective 10/01/2023: NOT COVERED for Part B Medical Benefit for Medicare-Medicaid Plan (MMP) members.

1 monthinitial authorization

40max billable unit

<24 monthsage limit (infantile spasms)

75 unitsdosing limit

Coverage Criteria for Repository Corticotropin Injection

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.

Covered indication and criteria

Repository corticotropin injection is covered under the Medical Benefit when used within the policy guidelines; coverage is subject to prior authorization and indication-specific criteria.

Covered indication: Infantile Spasms (West Syndrome).

ALL of the following

Clinical documentation indicating patient has a diagnosis of Infantile Spasms (West Syndrome).
Patient is less than 24 months old.
Must be used as monotherapy.
If the request is for Acthar Gel, the patient must have a documented contraindication, inadequate response, or intolerance to Cortrophin Gel.
Documentation that patient does not have a suspected congenital infection.
Dose does not exceed 75 units intramuscularly given twice daily for 2 weeks, then tapered over a 2-week period per the policy dosing schedule (per policy dosing schedule details).
Maximum billable unit referenced in coding = 40 units; standard initial authorization duration: 1 month.

Authorization and documentation: Coverage will be reviewed prospectively via the authorization process; requests must include required clinical documentation and meet the indication-specific criteria above.

Applicable Codes and Dosing References

Applicable HCPCS CodesHCPCSCovered

J0801	Injection, corticotropin (acthar gel), Up to 40 units
J0802	Injection, corticotropin (ANI), Up to 40 units

Infantile spasms dosing limit — dose ceiling and billing reference

Dose ceiling (per policy)Do not exceed 75 units intramuscularly given twice daily for 2 weeks, then taper the dose over a 2-week period per schedule

Maximum billable unit referencedMaximum billable unit listed = 40 units (policy references 35 billable units every 28 days)

Taper example (per policy text)Taper schedule example included in policy (stepwise reduction to 30 units morning, then 10 units, etc.)

Prior Authorization and Documentation Requirements

Prior Authorization

Prior authorization and required documentation

Coverage requests for repository corticotropin injection must be submitted prospectively through the prior authorization process and include clinical documentation demonstrating the diagnosis and that the request meets indication-specific criteria (for example, for infantile spasms: diagnosis of Infantile Spasms (West Syndrome), patient age <24 months, use as monotherapy, when Acthar Gel is requested a documented contraindication/inadequate response/intolerance to Cortrophin Gel, documentation that the patient does not have a suspected congenital infection, and dosing within the policy limits).

Submit request prospectively via authorization.
Include clinical documentation of diagnosis and evidence meeting the indication-specific requirements listed above.
For Acthar requests, include documentation of contraindication, inadequate response, or intolerance to Cortrophin Gel if applicable.
Include documentation ruling out suspected congenital infection and that dosing does not exceed policy limits.

Definitions and Condition Criteria

Acthar (repository corticotropin injection) — product definition and high-level indications

Product name (term)Acthar (repository corticotropin injection)

Primary pediatric indicationTreatment of infantile spasms in children under the age of 2

Other adult indication notedMultiple sclerosis (MS) exacerbations in adults

Safety summaryAssociated with multiple warnings and adverse effects including increased infection risk, adrenal insufficiency, hypertension, Cushing’s syndrome, growth/physical development effects, and decreased bone density

Infantile Spasms (West Syndrome) criteria — diagnostic and age requirements, monotherapy/response documentation

Required diagnostic documentationClinical documentation indicating a diagnosis of Infantile Spasms (West Syndrome)

Age requirementPatient must be less than 24 months old

Monotherapy requirementMust be used as monotherapy for the infantile spasms indication

Prior therapy requirement for Acthar requestsIf Acthar Gel is requested, there must be documented contraindication, inadequate response, or intolerance to Cortrophin Gel

Contraindication checkDocumentation that the patient does not have a suspected congenital infection

Dose limit (actionable)Dose must not exceed 75 units IM twice daily for 2 weeks then taper per policy schedule