Acthar — Blue Cross Blue Shield of Montana
Rare diseases other than infantile spasms (BCBS NM Fully Insured or NM HIM members)
Preferred products
- Acthar
Initial criteria
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Requested indication is a rare disease
- ONE of the following:
- - Patient has another FDA labeled indication for the requested agent and route of administration OR
- - Patient has another indication that is supported in compendia for the requested agent and route of administration
Approval duration
12 months