CurrentViva HealthPolicy IC-0003

Repository corticotropin injection (Acthar Gel, Cortrophin Gel)

Policy covers prior authorization, coverage criteria, dosing limits, and billing codes for repository corticotropin injection (Acthar Gel and Cortrophin Gel) for specified indications (infantile spasms and multiple sclerosis) for Viva Health commercial/non-Medicare lines; includes renewal, dosing, HCPCS and NDC information.

Policy Summary

PayerViva Health

PolicyRepository corticotropin injection (Acthar Gel, Cortrophin Gel)

Policy CodePolicy IC-0003

Change TypeClarified

Effective Date

Next Review Date

Key ActionPrior authorization required; initial authorization valid for 1 month and may be renewed monthly; provider must submit documentation meeting indication-specific criteria.

POLICY UPDATE CHANGES

Policy includes indication-specific max units per dosing interval and HCPCS/NDC coding for Acthar and Cortrophin.

2Covered Indications (listed)

2Products referenced

2HCPCS codes

Coverage Summary

Policy status: covered_with_criteria for repository corticotropin injection products Acthar Gel and Cortrophin Gel for the listed, covered indications: infantile spasms (West Syndrome) and multiple sclerosis, acute exacerbation. This policy applies to Viva Health commercial/non‑Medicare lines. Prior authorization is required — initial authorization is valid for 1 month and may be renewed monthly; providers must submit documentation that meets the indication‑specific criteria outlined in the policy (see provider actions / prior_auth and documentation requirements).