Cortrophin Gel (repository corticotropin) — Blue Cross Blue Shield of Montana
Other indications supported for Ohio members (Fully Insured or HIM Shop)
Preferred products
- Acthar
Initial criteria
- Member resides in Ohio
- Plan is Fully Insured or HIM Shop (SG)
- Patient does NOT have any FDA labeled contraindications to the requested agent
- 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 OR
- - Prescriber has submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective
Approval duration
12 months