Acthar Gel — Medical Mutual
Infantile spasms (West Syndrome)
Initial criteria
- Patient is under 2 years of age; AND
- Clinical documentation indicating patient has a diagnosis of infantile spasms (West Syndrome); AND
- Must be used as monotherapy; AND
- Documentation that patient does not have a suspected congenital infection
Reauthorization criteria
- Patient continues to meet indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc.; AND
- Disease response with treatment as indicated by resolution of symptoms and/or normalization of laboratory tests; AND
- Absence of unacceptable toxicity from the drug (examples include severe infections, elevated blood pressure, salt and water retention, gastrointestinal perforation and bleeding, gastric ulcer, behavioral and mood disturbances, posterior subcapsular cataracts, glaucoma, anaphylaxis, etc.)
Approval duration
1 month