Repository Corticotropin Injection (Acthar Gel and Purified Cortrophin Gel) (CPB 0762, reviewed 2025-12-08)
Summary
Aetna considers repository corticotropin injection (Acthar Gel and Purified Cortrophin Gel) for commercial medical plans, and precertification is required for both products for all Aetna participating providers and members in applicable plan designs. Aetna considers Acthar Gel medically necessary for infantile spasms in members under 2 years of age and considers its continuation medically necessary when the member has shown substantial clinical benefit, while Purified Cortrophin Gel is considered experimental, investigational or unproven for infantile spasms. Aetna considers repository corticotropin not medically necessary for diagnostic testing of adrenocortical function and for conditions such as acute exacerbations of multiple sclerosis in adults, rheumatic disorders, symptomatic sarcoidosis and edematous states in nephrotic syndrome, and experimental, investigational or unproven for conditions such as focal segmental glomerulosclerosis, dry eye disease and ocular sarcoidosis.
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