Acthar® (corticotrophin)

Authorization forms

Traditional & Optimized (03/2019)

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

Medicare: Not covered

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): J0800

Benefit: Pharmacy only

Notes: Up to 40 units, infantile spasms

Criteria for coverage: See PA forms