Acthar — Blue Cross Blue Shield of Oklahoma

Preferred products

• Acthar Gel (repository corticotropin)

Initial criteria

• For BCBS NM Fully Insured or NM HIM members: ALL of the following:
• - Patient has no FDA labeled contraindications to the requested agent
• - Requested indication is a rare disease
• - ONE of the following: (A) Patient has another FDA labeled indication for the requested agent and route of administration OR (B) Patient has another indication supported in compendia for the requested agent and route of administration
• For OH Fully Insured or HIM Shop (SG) members: ALL of the following:
• - Member resides in Ohio
• - Plan is Fully Insured or HIM Shop (SG)
• - Patient has no FDA labeled contraindications to the requested agent
• - ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber submitted TWO articles from major peer-reviewed professional medical journals supporting the proposed use as generally safe and effective (case studies not acceptable)

Approval duration

12 months