Korlym Prior Authorization (with Quantity Limit) Criteria - Medicare Part D

Initial Evaluation

Korlym and mifepristone 300 mg tablets will be approved when ALL of the following are met:

    1. The patient has a diagnosis of Cushing’s syndrome

AND

    2. ONE of the following:

        A. The patient has type 2 diabetes mellitus

OR

        B. The patient has glucose intolerance as defined by a 2-hour glucose tolerance test plasma glucose value of 140-199 mg/dL

AND

    3. ONE of the following:

        A. The patient has failed surgical resection

OR

        B. The patient is NOT a candidate for surgical resection

AND

    4. The patient does NOT have any FDA labeled contraindication(s) to the requested medication

AND

    5. ONE of the following:

        A. The requested quantity (dose) does NOT exceed the program quantity limit

OR

        B. BOTH of the following:

            i. The requested quantity (dose) is greater than the program quantity limit

AND

            ii. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months

Renewal Evaluation

Korlym and mifepristone 300 mg tablets will be approved when ALL of the following are met:

    1. The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria

AND

    2. The patient has a diagnosis of Cushing’s syndrome

AND

    3. The patient has had clinical benefit with the requested medication

AND

    4. The patient does NOT have any FDA labeled contraindications to the requested medication

AND

    5. ONE of the following:

        A. The requested quantity (dose) does NOT exceed the program quantity limit

OR

        B. BOTH of the following:

            i. The requested quantity (dose) is greater than the program quantity limit

AND

            ii. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months