CurrentUnitedHealthcarePolicy N/A

Repository corticotropin (Acthar Gel / Purified Cortrophin Gel) step therapy policy

UnitedHealthcare pharmacy clinical program defining step therapy and coverage criteria for Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP), including indication-specific approval rules, required prior steroid trial or contraindication, authorization duration, and program operational notes. Effective for the program starting 2025-06-01.

Policy Summary

PayerUnitedHealthcare

PolicyRepository corticotropin (Acthar Gel / Purified Cortrophin Gel) step therapy policy

Policy CodePolicy N/A

Change TypeAdministrative updates; added product

Effective DateJun 1, 2025

Next Review Date

Key ActionFor indications other than infantile spasms and opsoclonus-myoclonus, obtain documentation of failure, contraindication, or intolerance to corticosteroid treatment prior to authorization; authorizations for approved indications are issued for 12 months.

POLICY UPDATE CHANGES

Added Purified Cortrophin Gel to program with same coverage criteria as Acthar Gel (noted in historical changes March 2022).

Effective date for the 2025 program set to 2025-06-01 with P&T approval dates listed through 3/2025.

3Primary covered indications listed

12Authorization duration (months)

1Required prior trial class

UnitedHealthcare pharmacy clinical program defining step therapy and coverage criteria for Acthar Gel (repository corticotropin injection) and Purified Cortrophin Gel (repository corticotropin injection USP). Effective date: 2025-06-01. Coverage stance: covered_with_criteria. Covered indications include: diagnosis of infantile spasms in patients less than 2 years of age, opsoclonus-myoclonus syndrome, and other corticosteroid-responsive conditions when there is a history of failure, contraindication, or intolerance to corticosteroid therapy. Authorization duration for approved indications is 12 months.

Policy header facts

Effective date2025-06-01

Last review2025-03-01

StatusCURRENT

Authorization duration12 months

Required prior trial classCorticosteroids (required trial or documented contraindication for indications other than infantile spasms and opsoclonus-myoclonus)

Age threshold — infantile spasms< 2 years

OpenPayer

Repository corticotropin (Acthar Gel / Purified Cortrophin Gel) step therapy policy

Coverage Summary