CurrentCignaPolicy N/A

Cushing's - Mifepristone Prior Authorization Policy

Defines prior authorization requirements and medical necessity criteria for coverage of mifepristone (Korlym and generic) to control hyperglycemia secondary to endogenous Cushing's syndrome in adults with type 2 diabetes or glucose intolerance.

Policy Summary

PayerCigna

PolicyCushing's - Mifepristone Prior Authorization Policy

Policy CodePolicy N/A

Change TypeName revisedcoverage criteria consolidatedapproval options added

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that mifepristone is prescribed by or in consultation with an endocrinologist or Cushing's specialist.

SourceLink

POLICY UPDATE CHANGES

Patients awaiting surgery and patients awaiting therapeutic response after radiotherapy were added as options for approval under endogenous Cushing's syndrome.

Policy name changed from 'Cushing's - Korlym Prior Authorization Policy' to 'Cushing's - Mifepristone Prior Authorization Policy' and generic mifepristone was added throughout.

Separate conditions for 'Patient Awaiting Surgery' and 'Patient Awaiting Therapeutic Response After Radiotherapy' were removed and consolidated under Endogenous Cushing's Syndrome.

1 yearapproval duration

≥18minimum age

1prior trial required

04/01/2026review date

Coverage Criteria for Mifepristone (Korlym)

Initial approval — FDA-approved indication

Covered when ALL of the following are met:

FDA-Approved Indication for Endogenous Cushing's Syndrome: Approve for 1 year if the patient meets ALL of the following (A, B, C, D, and E)

A: Patient is ≥ 18 years of age≥ 18 years

B: Mifepristone is being used to control hyperglycemia secondary to hypercortisolism in patients who have type 2 diabetes mellitus or glucose intolerance

Policy Summary

PayerCigna

PolicyCushing's - Mifepristone Prior Authorization Policy

Policy CodePolicy N/A

Change TypeName revisedcoverage criteria consolidatedapproval options added

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that mifepristone is prescribed by or in consultation with an endocrinologist or Cushing's specialist.

SourceLink

On This Page

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Korlym® (mifepristone 300 mg tablets) and generic mifepristone are covered only when the approval criteria for the FDA‑approved indication of endogenous Cushing's syndrome are met. Coverage is limited to use to control hyperglycemia secondary to hypercortisolism in adults with type 2 diabetes mellitus or glucose intolerance who have failed surgery or are not surgical candidates. Approvals are issued for a specified duration; standard approval duration is 1 year when all criteria are satisfied.

Claims submitted without a covered diagnosis or without documentation demonstrating that the patient meets the coverage criteria will be denied as not covered. Prior authorization is required and mifepristone must be prescribed by or in consultation with an endocrinologist or a physician who specializes in the treatment of Cushing's syndrome for approval to be considered.

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for mifepristone (Korlym®) prescription benefit coverage. Approvals are provided for specified durations (e.g., 1 year for the FDA-approved indication). When approvals are given in months, 1 month = 30 days.

Applies to Korlym® (mifepristone 300 mg) and generics
Typical approval duration: 1 year for FDA‑approved endogenous Cushing's syndrome when criteria met

Step Therapy

Prior Medication Trial Required

Approval requires documentation that the patient has tried an alternate steroidogenesis inhibitor for endogenous Cushing's syndrome or is currently receiving mifepristone.

Required trial: ketoconazole OR Metopirone (metyrapone) OR Lysodren (mitotane) OR Signifor (pasireotide) OR Signifor LAR (pasireotide IM)
Exception: current use of mifepristone satisfies this requirement

Documentation Required

Prescriber and Duration Requirements

Mifepristone must be prescribed by or in consultation with an endocrinologist or a physician who specializes in the condition being treated. Approvals for the FDA‑approved indication (endogenous Cushing's syndrome) are for 1 year when all criteria are met.

Prescriber requirement: endocrinologist or specialist in Cushing's syndrome (prescribing or consult)
Approval duration example: 1 year for endogenous Cushing's syndrome when ALL criteria are met

Denial Risk

Billing and Coding / Denial Risk

Claims for mifepristone without a covered diagnosis or without meeting the prior authorization and clinical criteria will be denied. Ensure submitted claims include the covered diagnosis and appropriate procedure/drug codes and documentation of prior authorization.

Include covered diagnosis (e.g., endogenous Cushing's syndrome) and documentation that criteria A–E are met when applicable
Claims lacking prior authorization or covered codes/clinical documentation are at high risk for denial

Background

Mifepristone is a glucocorticoid (cortisol) receptor antagonist indicated to control hyperglycemia secondary to hypercortisolism in adults with endogenous Cushing's syndrome who have type 2 diabetes mellitus or glucose intolerance and who have failed surgery or are not surgical candidates.

Cushing's syndrome is a state of cortisol excess from internal sources such as a pituitary adenoma or adrenal tumor; treatment goals include normalizing cortisol levels and controlling the metabolic and clinical consequences, including hyperglycemia. Mifepristone acts by blocking the glucocorticoid receptor to mitigate the effects of excess cortisol on glucose metabolism.

OpenPayer

Cushing's - Mifepristone Prior Authorization Policy

Coverage Criteria for Mifepristone (Korlym)

Coding and Approval Duration

Provider Actions and Prior Authorization Requirements

Background

Definitions