Acthar Gel (repository corticotropin) — Blue Cross Blue Shield of Texas
rare diseases (specific plan exceptions)
Preferred products
- Acthar Gel (repository corticotropin)
Initial criteria
- Request is for BCBS NM Fully Insured or NM HIM member OR member resides in Ohio with Fully Insured or HIM Shop (SG) plan AND
- Patient does NOT have any FDA labeled contraindications to requested agent AND
- 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 that is supported in compendia (DrugDex level 1, 2A, or 2B; AHFS-DI supportive text; NCCN 1 or 2A; Clinical Pharmacology supportive text; LexiDrugs level A; peer-reviewed medical literature) OR
- C. Prescriber has submitted TWO peer-reviewed journal articles supporting proposed use (e.g., JAMA, NEJM, Lancet; randomized, double blind, placebo controlled; case studies not acceptable)
Approval duration
12 months