Cortrophin Gel (repository corticotropin) — Blue Cross Blue Shield of Montana

Preferred products

• Acthar (repository corticotropin)

Initial criteria

• Patient has a diagnosis of infantile spasms
• Patient age < 24 months
• ONE of the following:
• - Requested agent is a preferred agent OR
• - Prescriber states the patient is currently being treated with the requested agent AND the patient is currently stable on the requested agent OR
• - Patient has tried and had an inadequate response to ONE preferred agent OR
• - ONE preferred agent was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event OR
• - Patient has an intolerance or hypersensitivity to ONE preferred agent that is NOT expected to occur with the requested agent OR
• - Patient has an FDA labeled contraindication to ALL preferred agents that is NOT expected to occur with the requested agent OR
• - ONE preferred agent is expected to be ineffective based on the known clinical characteristics of the patient and the known characteristics of the prescription drug; OR cause a significant barrier to the patient’s adherence of care; OR worsen a comorbid condition; OR decrease the patient’s ability to achieve or maintain reasonable functional ability in performing daily activities; OR cause an adverse reaction or cause physical or mental harm OR
• - ONE preferred agent is not in the best interest of the patient based on medical necessity OR
• - Patient has tried another prescription drug in the same pharmacologic class or with the same mechanism of action as ONE preferred agent and that prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Requested quantity (dose) is within FDA labeled dosing for the requested indication OR there is support for therapy with a higher dose for the requested indication

Approval duration

12 months