Repository Corticotropin (H.p. Acthar Gel) - Medical Necessity Request Form

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Member Name: ______________________________ Member ID: ________________ Member DOB: ________________
Drug Name: _____________________________ Strength: _______________ Directions: ______________________________________
Physician Name: __________________________ Physician Phone #: _________________________ Specialty: _____________________
Physician Fax #: _____________________ Pharmacy Name: ____________________________Pharmacy Phone: __________________
Horizon NJ Health
Repository Corticotropin (H.P. Acthar Gel) – Medical Necessity Request
1. Please indicate if member has any of the following contraindications to therapy:
□ Administration via intravenous route
□ Recent surgery
□ Infants with suspected congenital infections
□ History of or the presence of a peptic ulcer
□ Administration of live or live attenuated
□ Congestive heart failure
□ Uncontrolled hypertension
vaccines in patients receiving
□ Primary adrenal insufficiency
immunosuppressive doses of H.P Acthar Gel.
□ Scleroderma
□ Adrenocortical hyperfunction
□ Osteoporosis
□ Sensitivity to proteins of porcine origin
□ Systemic fungal infections
□ NONE
□ Ocular herpes simplex
2. Diagnosis Information (please select diagnosis and provide requested information):
□ Infantile Spasms/West Syndrome
- What is the member’s current weight? _______ lbs
Date Taken: ___________________
_______ kg
- What is the member’s current height? _______ feet ______inches
Date Taken: ______________
_______ cm
* Please note, height and weight must be from within the past 60 days.
□ Multiple Sclerosis
- Is the member having an acute exacerbation? Yes or No
- Is the condition corticosteroid-responsive? Yes or No
- Has the member tried a systemic corticosteroid for the current exacerbation?
□ Yes
□ No - Would the MD consider trying corticosteroid therapy for this member instead? Yes or No
- If not, please provide the clinical reason why a systemic corticosteroid cannot be tried:
______________________________________________________________________________________________
______________________________________________________________________________________________
Physician office's signature*_________________________________ Print Name________________________________
*Form must be completed and signed by physician or licensed representative from the physician’s office.
1 of 1
Rev. 03/16
HNJH Fax #: 888-567-0681
Page

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