mifepristone — Blue Cross Blue Shield of Kansas

Initial criteria

• ONE of the following:
• A. The patient is continuing therapy AND ONE of the following:
• 1. The patient has been treated with the requested agent (not starting on samples) within the past 90 days OR
• 2. The prescriber states the patient has been treated with the requested agent (not starting on samples) within the past 90 days and is at risk if therapy is changed OR
• B. The patient has a diagnosis of Cushing’s syndrome AND
• 1. If the patient has an FDA labeled indication, then ONE of the following:
• A. The patient’s age is within FDA labeling for the requested indication OR
• B. There is support for using the requested agent for the patient’s age for the requested indication 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 had an inadequate response to surgical resection OR
• B. The patient is not a candidate for surgical resection AND
• If the request is for a brand agent with an available generic equivalent:
• ONE of the following:
• A. The patient has an intolerance or hypersensitivity to the generic equivalent not expected with the brand agent OR
• B. The patient has an FDA labeled contraindication to the generic equivalent not expected with the brand agent OR
• C. There is clinical support for the use of the brand agent over the generic equivalent AND
• The prescriber is a specialist (e.g., endocrinologist) or has consulted with a specialist AND
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• The requested dose does NOT exceed 20 mg/kg/day

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• The patient has had clinical benefit with the requested agent AND
• If the request is for a brand agent with an available generic equivalent:
• ONE of the following:
• 1. The patient has an intolerance or hypersensitivity to the generic equivalent not expected with the brand agent OR
• 2. The patient has an FDA labeled contraindication to the generic equivalent not expected with the brand agent OR
• 3. There is clinical support for the use of the brand agent over the generic equivalent AND
• The prescriber is a specialist (e.g., endocrinologist) or has consulted with a specialist AND
• The patient does NOT have any FDA labeled contraindications to the requested agent AND
• The requested dose does NOT exceed 20 mg/kg/day

Approval duration

initial 6 months; renewal 12 months