Acthar Gel

Drug - H.P. Acthar Gel (corticotropin)

April 2019

Therapeutic area - Miscellaneous

Approval criteria

If patient diagnosis is infantile spasms or multiple sclerosis:

• Patient cannot be treated with IV methylprednisolone or oral corticosteroids AND
• Accepted treatment guidelines have been followed for the specific disease state

For other disease states:

• Patient cannot be treated with IV methylprednisolone or oral corticosteroids AND
• Provider must state intended use, and provides published and peer reviewed literature supporting use in the specific disease state

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411