Blue Cross & Blue Shield of MississippiCommercial · Coverage · Pharmacy · MS · Neurology, PharmacyMedium impact
State and School Employees' Health Insurance Plan - ACTH Gel (Repository Corticotropin Injection)
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Repository corticotropin injection (H.P. Acthar Gel) may be considered medically necessary for the treatment of infantile spasms (West syndrome). It is considered investigational for diagnostic testing of adrenocortical function, for corticosteroid-responsive conditions unless there are medical contraindications or intolerance to corticosteroids that are not also expected with this injection, and for conditions not responsive to corticosteroid therapy, including tobacco cessation, acute gout and childhood epilepsy. Services related to delivery or administration of a medication determined to be not medically necessary are also considered not medically necessary, and the most recent policy history entry, dated 01/10/2025, states the policy was reviewed with no changes.
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01Billing team: Perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting before billing this drug.
02Billing team: For use in corticosteroid-responsive conditions, the record must document medical contraindications or intolerance to corticosteroids that are not also expected to occur with this injection, since otherwise the use is considered investigational.
03Billing team: For Federal Employee Program members, the policy notes that FEP may dictate that FDA-approved drugs may not be considered investigational and may be assessed only on the basis of medical necessity.
Codes mentioned
96372G40.821G40.824
Original notice
State and School Employees' Health Insurance Plan - ACTH Gel (Repository Corticotropin Injection)
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