Acthar Gel: Enhanced Specialty Guideline Management Features Stringent Prior Authorization

Solution offers payors flexibility and choice
October 14, 2021
Vice President & Head of PBM & Specialty Product Innovation

As the specialty landscape continues to evolve, close surveillance of industry trends and customer feedback provides new opportunities to manage specialty spend.

Acthar Gel is a hormonal injection that has 19 FDA-approved indications. It is used to treat conditions such as multiple sclerosis, psoriatic or rheumatoid arthritis, ankylosing spondylitis, lupus, severe allergic reactions, breathing disorders and inflammatory conditions of the eyes. Use of H.P. Acthar for many of the approved conditions is considered not medically necessary.

Acthar Gel is currently only available as a brand-name drug and costs more than $40,000 per vial.Ibid.

Treatment varies based on indication, dose and duration of treatment. Acthar Gel has been and continues to be a focus for our clients due to its broad labeling and high cost.

difference in denial rateCVS Health Enterprise Analytics, PA Performance Dashboard Q1 2019-Q2 2021, accessed August 2021. Reflects performance of standard and enhanced SGM programs based on episode outcomes which captures rejects (70 &75) followed by PA (if any) and the fill outcomes. Based on historical behaviors, this may be ~10% of episode. Excludes New to Market Block and claims data for Discount Card, Restricted Data, and certain other clients excluded. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors.*

We launched Enhanced Specialty Guideline Management (SGM) Acthar Gel in September 2020. This program features more stringent prior authorization (PA) criteria that only covers the indication for infantile spasms, providing clients with greater choice and flexibility to manage this therapy. Since the launch, nearly 400 clients have adopted this program.CVS Specialty Internal Data, October 2021.

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October 14, 2021
Vice President & Head of PBM & Specialty Product Innovation

FDA (U.S. Food and Drug Administration). UM (utilization management).

The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted.

Savings will vary based upon a variety of factors including things such as plan design, demographics and programs implemented by the plan.

CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.

This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Health.

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