Purified Cortrophin Gel — United Healthcare

Initial criteria

• ONE of the following: Rheumatic disorders (psoriatic arthritis, rheumatoid arthritis incl. juvenile, ankylosing spondylitis, acute gouty arthritis)
• OR Collagen diseases (systemic lupus erythematosus or systemic dermatomyositis/polymyositis)
• OR Dermatologic diseases (severe erythema multiforme/Stevens-Johnson syndrome or severe psoriasis)
• OR Allergic states (atopic dermatitis or serum sickness)
• OR Ophthalmic diseases (severe acute/chronic allergic or inflammatory processes of the eye such as allergic conjunctivitis, keratitis, iritis/iridocyclitis, diffuse posterior uveitis/choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation)
• OR Respiratory diseases (symptomatic sarcoidosis)
• OR Edematous states (to induce diuresis or remission of proteinuria in nephrotic syndrome without uremia of idiopathic or lupus etiology)

Reauthorization criteria

• Documentation of positive clinical response to Purified Cortrophin Gel therapy

Approval duration

12 months