Acthar® (corticotrophin)

Authorization forms

Traditional & Optimized (03/2018)

Medicaid: This is considered a carve out drug. Please contact Medicaid fee for service for coverage.

Medicare: Not covered

For further information on medical drugs, please see the Injectable drugs page.

Code(s): J0800

Benefit: Pharmacy only

Notes: Up to 40 units, infantile spasms

Criteria for coverage: See PA forms