Medical Policy

Effective Date:07/01/2012 Title:Korlym (Mifepristone)
Revision Date:10/01/2017 Document:BI369:00
CPT Code(s):None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Korlym (Mifepristone) requires prior authorization.

2)    Korlym is used to treat adult patients with hyperglycemia secondary to hypercortisolism with endogenous Cushing’s syndrome who have type 2 diabetes or glucose intolerance and have failed surgery or are not candidates for surgery.

3)    Korlym is covered under the pharmacy benefit as a specialty drug.

Medical Statement

Korlym is considered medically necessary for adult patients with hyperglycemia secondary to hypercortisolism when all of the following criteria are met:

A.    Patient has diagnosis of endogenous Cushing’s syndrome (E24.0–E24.3, E24.8–E24.9); AND

  1. Patient has type 2 diabetes mellitus (E08.00–E08.9) or glucose intolerance (R73.01–R73.09); AND
  2. Patient has failed surgery or is not a candidate for surgery; AND
  3. Korlym is prescribed by or in consultation with an endocrinologist; AND
  4. If female, patient is not pregnant.

 

Reauthorization Criteria

Authorization for continued used shall be reviewed at least every 6 months to confirm one of the following:

A.    Patient has improved glucose tolerance while on Korlym therapy; OR

B.    Patient has stable glucose tolerance while on Korlym therapy.

Limits

Korlym is limited to a maximum 120 tablets per month.

Reference

1)    Korlym Product Information.  Corcept Pharmaceuticals.  February  2012

2)    Clinical Pharmacology. Accessed online 7/17/2017.

Addendum:

Effective 10/01/2017:  Clarified coverage criteria and added re-authorization criteria

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.