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Korlym (mifepristone) Prior Authorization with Quantity Limit Program Summary

Policy Number: PH-1054

 

This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies. 

POLICY REVIEW CYCLE                                                                                                                                                                           

Effective Date

Date of Origin 

04-01-2024            

10-01-2012

FDA APPROVED INDICATIONS AND DOSAGE

Agent(s)

FDA Indication(s)

Notes

Ref#

Korlym®

(mifepristone)

Tablet*

To control hyperglycemia secondary to hypercortisolism in adult patients with endogenous Cushing’s syndrome who have type 2 diabetes mellitus or glucose intolerance and have failed surgery or are not candidates for surgery

 

Limitations of Use: Should not be used in the treatment of patients with type 2 diabetes unless it is secondary to Cushing’s syndrome

* - generic available

1

See package insert for FDA prescribing information:  https://dailymed.nlm.nih.gov/dailymed/index.cfm

CLINICAL RATIONALE

Cushing's Syndrome

Cushing's syndrome denotes pathologic hypercortisolism as a result of excessive adrenocorticotropic hormone (ACTH) production or autonomous adrenal production of cortisol. This potentially lethal disorder is associated with significant comorbidities including hypertension, diabetes, coagulopathy, cardiovascular disease, infections, and fractures. As a result, even after cure of hypercortisolism, mortality rates may be increased. Because of this it is important to make the diagnosis as early in the disease course as possible to prevent additional morbidity and residual disease. Signs and symptoms of Cushing’s syndrome are broad and often common among the general population such as obesity, depression, diabetes, hypertension, or menstrual irregularities. Some features are more discriminatory and unique to Cushing’s syndrome such as reddish-purple striae, plethora, proximal muscle weakness, bruising with no obvious trauma, and unexplained osteoporosis.(5)

Guidelines recommend a multidisciplinary team, including an endocrinologist, providing education and treatment options to the patient. Goals of treatment in Cushing’s syndrome include reversal of clinical features, normalization of biochemical changes with minimal morbidity, and long-term control without recurrence. Surgical resection of the causal lesion(s) is the first-line approach. When surgery is delayed, contraindicated, or unsuccessful, second-line treatments, including medical therapy, bilateral adrenalectomy, and radiation therapy, must be considered. Glucocorticoid antagonists, such as mifepristone, are suggested in patients with diabetes or glucose intolerance who are not surgical candidates or who have persistent disease after surgery.(2)

The American Diabetes Association defines impaired glucose tolerance (glucose intolerance) in prediabetes as plasma glucose of 140 mg/dL to 199 mg/dL (7.8 mmol/L to less than 11.1 mmol/L), and in diabetes as plasma glucose of greater than or equal to 200 mg/dL (11.1 mmol), after the oral glucose tolerance test (OGTT). The OGTT is a two-hour test that checks plasma glucose levels before and 2 hours after drinking a glucose-containing drink.(4)

Efficacy (1)

The safety and efficacy of Korlym in the treatment of endogenous Cushing’s syndrome was evaluated in an uncontrolled, open-label, 24-week, multicenter clinical study. The study enrolled 50 subjects with clinical and biochemical evidence of hypercortisolemia despite prior surgical treatment and radiotherapy. The reasons for medical treatment were failed surgery, recurrence of disease, and poor medical candidate for surgery. Patients belonged to one of two cohorts: a diabetes cohort or a hypertension cohort. While results in the hypertension cohort showed no changes in mean systolic and diastolic blood pressures at the end of the trial, the diabetes cohort showed improvements in glucose response [defined as a greater than or equal to 25% reduction from baseline in glucose area under the curve (AUC) in standard oral glucose tolerance test] in 60% of patients, and reduction in glycated hemoglobin (HbA1c) in all patients.

 

Safety (1)

Mifepristone has a boxed warning for pregnancy termination. Mifepristone has potent antiprogestational effects and will result in the termination of pregnancy. Pregnancy must therefore be excluded before the initiation of treatment with mifepristone, or if the treatment is interrupted for more than 14 days in females of reproductive potential.

 

Mifepristone is contraindicated in:

  • Pregnancy
  • Patients taking drugs metabolized by CYP3A such as simvastatin, lovastatin, and CYP3A4 substrates with narrow therapeutic ranges, such as cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, and tacrolimus
  • Patients receiving systemic corticosteroids for lifesaving purposes (e.g., immunosuppression after organ transplantation)
  • Women with a history of unexplained vaginal bleeding or with endometrial hyperplasia with atypia or endometrial carcinoma
  • Patients with known hypersensitivity to mifepristone or to any of the product components

REFERENCES                                                                                                                                                                           

Number

Reference

1

Korlym prescribing information. Corcept Therapeutics Inc. November 2019.

2

Nieman L, Biller B, et al. Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015;100:2807–2831.

3

Nieman L, Biller B, et al. Diagnosis of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2008;93(5):1526-1540. Reference no longer used.

4

American Diabetes Association Professional Practice Committee.  “Classification and Diagnosis of Diabetes: Standards of Medical care in Diabetes-2023.”  Diabetes Care 2023; 46(Supplement_1): S19-S40.  Available at: https://diabetesjournals.org/care/issue/46/Supplement_1

5

Endocrine Society. Cushing’s disease. Accessed at: https://www.hormone.org/diseases-and-conditions/cushings-disease

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Target Brand Agent(s)

Target Generic Agent(s)

Strength

Targeted MSC

Available MSC

Final Age Limit

Preferred Status

Korlym

mifepristone tab

300 MG

M ; N ; O ; Y

O ; Y

POLICY AGENT SUMMARY QUANTITY LIMIT

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

QL Amount

Dose Form

Day Supply

Duration

Addtl QL Info

Allowed Exceptions

Targeted NDCs When Exclusions Exist

Korlym

mifepristone tab

300 MG

120

Tablets

30

DAYS

CLIENT SUMMARY – PRIOR AUTHORIZATION

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Korlym

mifepristone tab

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

CLIENT SUMMARY – QUANTITY LIMITS

Target Brand Agent Name(s)

Target Generic Agent Name(s)

Strength

Client Formulary

Korlym

mifepristone tab

300 MG

Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

Initial Evaluation

Target Agent will be approved when ALL of the following are met:

  1. The patient has a diagnosis of Cushing’s syndrome AND
  2. If the patient has an FDA approved indication, then ONE of the following:
    1. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
    2. The prescriber has provided information in support of using the requested agent for the patient’s age for the requested indication AND
  3. ONE of the following:
    1. The patient has type 2 diabetes mellitus OR
    2. The patient has glucose intolerance as defined by a 2-hr glucose tolerance test plasma glucose value of 140-199 mg/dL AND
  4. ONE of the following:
    1. The patient has had an inadequate response to surgical resection OR
    2. The patient is NOT a candidate for surgical resection AND
  5. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  6. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  7. The requested dose does NOT exceed 20 mg/kg/day

Length of Approval: 6 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

 

Renewal Evaluation

Target Agent(s) will be approved when ALL of the following are met:

  1. The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  2. The patient has had clinical benefit with the requested agent AND
  3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., endocrinologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND
  4. The patient does NOT have any FDA labeled contraindications to the requested agent AND
  5. The requested dose does NOT exceed 20 mg/kg/day

Length of Approval: 12 months

NOTE: If Quantity Limit applies, please refer to Quantity Limit Criteria.

QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL

Module

Clinical Criteria for Approval

QL with PA

Quantity Limit for the Target Agent(s) will be approved when ONE of the following is met:

  1. The requested quantity (dose) does NOT exceed the program quantity limit OR
  2. ALL of the following:
    1. The requested quantity (dose) exceeds the program quantity limit AND
    2. The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND
    3. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit

Length of Approval: Initial: 6 months; Renewal: 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.

Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

 

 

 

 

Commercial _ PS _ Korlym_PAQL _ProgSum_ 04-01-2024