Your patients’ Acthar prescription is only available through specialty pharmacy distribution and cannot be filled at a retail pharmacy. To get the prescription and reimbursement process started, download, fill out, and fax in the referral form below, so the Acthar Support & Access Program (A.S.A.P.) can begin your request.

To avoid processing delays, please make sure:

  • To include phone numbers for your direct office contact and backup office contact
  • Provide clinical documentation and copies of detailed patient charts/notes

Since prior authorizations are common, a statement of medical necessity may be needed.

If you have any questions or need assistance filling out your form, contact A.S.A.P.

Phone: 1-888-435-2284
Fax: 1-877-937-2284
Monday to Friday, 8 AM to 8 PM ET.

A.S.A.P. will keep you and your patient informed about the delivery status of their Acthar prescription.