Acthar

(corticotropin)
Acthar H.P. Gel 80 UNT/ML Injectable Solution
NO BLACK BOX WARNING

Dosage & administration

drug label

Acthar prescribing information

prior authorization

Acthar prior authorization resources

Most recent Acthar prior authorization forms

View By Payer
Updated: Jun 08, 2023UPMC Health Plan - Acthar Gel Prior Authorization Form
Updated: May 30, 2023Cigna - Acthar Prior Authorization Form
Updated: May 29, 2023Blue Cross Blue Shield of Michigan - Acthar Gel Prior Authorization Form (Medical Benefit)
Updated: May 25, 2023Independence Health - Medicare Part D Acthar Prior Authorization Form
Updated: May 24, 2023Aetna - Acthar Prior Authorization Form

OTHER
Coverage Authorization Appeals

PDF
Patient Appeals Letter Template

PDF
Patient Appeals Letter Template - Spanish
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Benefits investigation

PDF
Referral Form: Rheumatology

PDF
Referral Form: Sarcoidosis (Pulmonology)

PDF
Referral Form: Ophthalmology

PDF
Referral Form: Nephrology

PDF
Referral Form: Multiple Sclerosis (Neurology)

PDF
Referral Form: Infantile Spasms (Neurology)
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Reimbursement help (FRM)

OTHER
Receive Assistance from an FRM Regarding Reimbursement Information
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financial assistance

Acthar financial assistance options

Co-pay savings program

commercial only

PDF
Referral Form: Rheumatology

PDF
Referral Form: Sarcoidosis (Pulmonology)

PDF
Referral Form: Ophthalmology

PDF
Referral Form: Nephrology

PDF
Referral Form: Multiple Sclerosis (Neurology)

PDF
Referral Form: Infantile Spasms (Neurology)
Enroll in Patient Savings Program
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Bridge program

commercial only

PDF
Referral Form: Rheumatology

PDF
Referral Form: Sarcoidosis (Pulmonology)

PDF
Referral Form: Ophthalmology

PDF
Referral Form: Nephrology

PDF
Referral Form: Infantile Spasms (Neurology)
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Foundation programs

under insured
no insurance
goverment insurance
65+

OTHER
Acthar Patient Assistance Program
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patient education

Acthar patient education

Getting started on Acthar

BRAND PAGE
Instructions For Use: All Indications
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

BRAND PAGE
Instructions For Use (Spanish): All Indications
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link
To share resource; ask patient to:
1.Pull out phone
2.Open camera
3.Scan QR code with camera
4.Tap link

Patient toolkit

PDF
Doctor Discussion Guide: Appeals
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
RA Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
SLE Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
DM/PM Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Sarcoidosis Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Inflammatory Eye Conditions Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Nephrotic Syndrome Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
MS Relapse Fact Sheet
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Caregiver Brochure
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Treatment Journal Calendar
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Treatment Journal Calendar - Spanish
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Injection Tracker
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Patient Support Brochure
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Infantile Spasms Caregiver Brochure
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Infantile Spasms Injection Guide
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Infantile Spasms Treatment Tracker
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Patient Bill of Rights
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

PDF
Discussing Your Appeal Guide
ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link