How to Get Acthar for Your Patients

Starting patients on Acthar

Step 1

Step_1

HCP prescribes Acthar

  • HCP faxes Acthar Support Form (with clinical info*) to 1-877-221-9505
  • Confirmation and case numbers are faxed to HCP office

Step 2

Step_2

HCP and patient are contacted

Acthar Specialty Pharmacy:

  • Communicates coverage and facilitates PA or appeals (when needed)
  • Calls patient to confirm co-pay and schedule delivery

Step 3

Step_3

Acthar arrives at patient’s home

  • Container is refrigerated and Acthar is ready for use
  • Patient’s signature is required for delivery

Step 4

Step_4

Support anytime with ActharPACT

To supplement your efforts, patients have access to a 24/7 nurse hotline, educational materials, and follow-up support. Patients can call 1-877-546-PACT (1-877-546-72281-877-546-7228) or visit ActharPACT.com

*Clinical information includes: letter of medical necessity, chart notes, current therapy, and previous therapy results and dates.

Physician referrals

Acthar is only available through Specialty Pharmacy distribution. Your patients cannot get their Acthar prescription filled at a retail pharmacy.

When filling out the Referral/Prescription Form, following these guidelines will help maximize success with the payer:

  • Be sure to include phone numbers for your direct office contact and backup office contact
  • Consider providing all relevant clinical documentation
  • A Statement of Medical Necessity may be needed

If the referral is denied, you may have the option to appeal

  • If you receive a denial letter, or any correspondence directly from the payer, fax it to the Acthar Specialty Pharmacy immediately
  • If the appeal process is unsuccessful, qualified patients will be referred to the Patient Assistance Program to receive Acthar at no cost

If you have any questions about the Acthar referral process or the status of an existing referral, please call 1-877-463-88031-877-463-8803, Monday–Friday, 8 am–8 pm ET.

Program administered via a third-party organization.

How to fill out the Referral/Prescription Form

Download the Referral/Prescription Form and follow the instructions on the right for each section of the Referral Form pictured below.

Opth_StartForm

Section 1

Complete provider information

Section 2

Fill out patient information

Section 3

Acquire insurance information

Section 4

Fill in prescription details

Section 5

Review authorization with patient and, if patient is present,
have him or her sign and date

Form may be sent if patient has not signed. The absence of a signature will not impede or stop the referral to shipment process.

Section 6

Sign and date to initiate the prescription

Acthar is indicated for severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: keratitis, iritis, iridocyclitis, diffuse posterior uveitis and choroiditis, optic neuritis, chorioretinitis, anterior segment inflammation.

*Clinical information includes: letter of medical necessity, chart notes, current therapy, and previous therapy results and dates.

Physician referrals

Acthar is only available through Specialty Pharmacy distribution. Your patients cannot get their Acthar prescription filled at a retail pharmacy.

When filling out the Referral/Prescription Form, following these guidelines will help maximize success with the payer:

  • Be sure to include phone numbers for your direct office contact and backup office contact
  • Consider providing all relevant clinical documentation
  • A Statement of Medical Necessity may be needed

If the referral is denied, you may have the option to appeal

  • If you receive a denial letter, or any correspondence directly from the payer, fax it to the Acthar Specialty Pharmacy immediately
  • If the appeal process is unsuccessful, qualified patients will be referred to the Patient Assistance Program to receive Acthar at no cost

If you have any questions about the Acthar referral process or the status of an existing referral, please call 1-877-463-88031-877-463-8803, Monday–Friday, 8 am–8 pm ET.

Program administered via a third-party organization.

How to fill out the Referral/Prescription Form

Download the Referral/Prescription Form and follow the instructions on the right for each section of the Referral Form pictured below.

Opth_StartForm

Section 1

Complete provider information

Section 2

Fill out patient information

Section 3

Acquire insurance information

Section 4

Fill in prescription details

Section 5

Review authorization with patient and, if patient is present, have him or her sign and date

Form may be sent if patient has not signed. The absence of a signature will not impede or stop the referral to shipment process.

Section 6

Sign and date to initiate the prescription

Important Safety Information

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Contraindications

  • Acthar should never be administered intravenously
  • Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of Acthar

Important Safety Information

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Contraindications

  • Acthar should never be administered intravenously
  • Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of Acthar
  • Acthar is contraindicated where congenital infections are suspected in infants
  • Acthar is contraindicated in patients with scleroderma, osteoporosis, systemic fungal infections, ocular herpes simplex, recent surgery, history of or the presence of a peptic ulcer, congestive heart failure, uncontrolled hypertension, primary adrenocortical insufficiency, adrenocortical hyperfunction or sensitivity to proteins of porcine origins

Warning and Precautions

  • The adverse effects of Acthar are related primarily to its steroidogenic effects
  • Acthar may increase susceptibility to new infection or reactivation of latent infections
  • Suppression of the hypothalamic-pituitary-axis (HPA) may occur following prolonged therapy with the potential for adrenal insufficiency after withdrawal of the medication. Adrenal insufficiency may be minimized by tapering of the dose when discontinuing treatment. During recovery of the adrenal gland patients should be protected from the stress (e.g. trauma or surgery) by the use of corticosteroids. Monitor patients for effects of HPA suppression after stopping treatment
  • Cushing’s Syndrome may occur during therapy but generally resolves after therapy is stopped. Monitor patients for signs and symptoms
  • Acthar can cause elevation of blood pressure, salt and water retention, and hypokalemia. Blood pressure, sodium and potassium levels may need to be monitored
  • Acthar often acts by masking symptoms of other diseases/disorders. Monitor patients carefully during and for a period following discontinuation of therapy
  • Acthar can cause GI bleeding and gastric ulcer. There is also an increased risk for perforation in patients with certain gastrointestinal disorders. Monitor for signs of bleeding
  • Acthar may be associated with central nervous system effects ranging from euphoria, insomnia, irritability, mood swings, personality changes, and severe depression, and psychosis. Existing conditions may be aggravated
  • Patients with comorbid disease may have that disease worsened. Caution should be used when prescribing Acthar in patients with diabetes and myasthenia gravis
  • Prolonged use of Acthar may produce cataracts, glaucoma and secondary ocular infections. Monitor for signs and symptoms
  • Acthar is immunogenic and prolonged administration of Acthar may increase the risk of hypersensitivity reactions. Neutralizing antibodies with chronic administration may lead to loss of endogenous ACTH activity
  • There is an enhanced effect in patients with hypothyroidism and in those with cirrhosis of the liver
  • Long-term use may have negative effects on growth and physical development in children. Monitor pediatric patients
  • Decrease in bone density may occur. Bone density should be monitored for patients on long-term therapy
  • Pregnancy Class C: Acthar has been shown to have an embryocidal effect and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus

Adverse Reactions

  • Common adverse reactions for Acthar are similar to those of corticosteroids and include fluid retention, alteration in glucose tolerance, elevation in blood pressure, behavioral and mood changes, increased appetite and weight gain
  • Specific adverse reactions reported in IS clinical trials in infants and children under 2 years of age included: infection, hypertension, irritability, Cushingoid symptoms, constipation, diarrhea, vomiting, pyrexia, weight gain, increased appetite, decreased appetite, nasal congestion, acne, rash, and cardiac hypertrophy. Convulsions were also reported, but these may actually be occurring because some IS patients progress to other forms of seizures and IS sometimes mask other seizures, which become visible once the clinical spasms from IS resolve

Other adverse events reported are included in the full Prescribing Information.

Please see full Prescribing Information.

References