Effective November 25, 2014, Independence?s medical policy
on repository corticotropin (H.P. Acthar® Gel Injection) will be
updated to reflect new medical necessity coverage criteria. According to the
new version of the policy, Independence will only approve the use of H.P.
Acthar® Gel Injection when both of the following criteria are
met:
- The individual is diagnosed with West syndrome (infantile spasms).
- The individual is age 2 or younger.
Independence will no longer consider H.P. Acthar® Gel
Injection eligible for coverage for conditions that do not meet these criteria
because the drug is considerably more costly than alternative conventional
corticosteroid and/or immunosuppressive therapies that are at least as likely
to produce equivalent results in the diagnosis or treatment of the individual?s
illness, injury, or disease. Therefore, as of November 25, 2014, Independence
will no longer approve requests for H.P. Acthar® Gel Injection
for uses such as, but not limited to, the following:
- multiple sclerosis;
- rheumatic disorders (e.g., psoriatic arthritis, rheumatoid arthritis,
juvenile rheumatoid arthritis, ankylosing spondylitis);
- collagen diseases (e.g., systemic lupus erythematosus, systemic
dermatomyositis [polymyositis]);
- dermatologic disease (e.g., severe erythema multiforme, Stevens-Johnson
syndrome);
- allergic states (e.g., serum sickness);
- ophthalmic diseases (e.g., keratitis, iritis, iridocyclitis, diffuse
posterior uveitis, choroiditis, optic neuritis, chorioretinitis, anterior
segment inflammation);
- respiratory conditions (e.g., symptomatic sarcoidosis);
- to induce a diuresis or a remission of proteinuria in nephrotic syndrome
without uremia of the idiopathic type or due to lupus erythematosus;
- corticosteroid-responsive conditions;
- diagnostic testing for adrenocortical function.
Physicians can review the Notification for Medical Policy #08.01.12a:
Repository Corticotropin (H.P. Acthar® Gel Injection) by going
to our Medical Policy Portal,
selecting Accept and Go to Medical Policy Online, and then typing the
policy name or number in the Search box.