Corticoids Acth

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Drug Use Review Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
63004871201 ACTHAR SELFJECT corticotropin PEN INJCTR 40 unit/0.5 mL Y N Pharmacy PA
63004871204 ACTHAR SELFJECT corticotropin PEN INJCTR 40 unit/0.5 mL Y N Pharmacy PA
63004871101 ACTHAR SELFJECT corticotropin PEN INJCTR 80 unit/mL Y N Pharmacy PA
63004871104 ACTHAR SELFJECT corticotropin PEN INJCTR 80 unit/mL Y N Pharmacy PA
62559086135 CORTROPHIN corticotropin SYRINGE 40 unit/0.5 mL Y N Pharmacy PA
62559086111 CORTROPHIN corticotropin SYRINGE 80 unit/mL Y N Pharmacy PA
63004871001 ACTHAR corticotropin VIAL 80 unit/mL Y N Pharmacy PA
63004871002 ACTHAR corticotropin VIAL 80 unit/mL Y N Pharmacy PA
62559086011 CORTROPHIN corticotropin VIAL 80 unit/mL Y N Pharmacy PA
62559086015 CORTROPHIN corticotropin VIAL 80 unit/mL Y N Pharmacy PA
00548590000 CORTROSYN cosyntropin VIAL 0.25 mg Y N  
00781344071 COSYNTROPIN cosyntropin VIAL 0.25 mg Y N  
00781344095 COSYNTROPIN cosyntropin VIAL 0.25 mg Y N  
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