Pharmacy Prior Authorization Criteria

Lifyorli (relacorilant) - PA, NF

Indications for Prior Authorization

Lifyorli (relacorilant)

• For diagnosis of Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer
  Indicated in combination with nab-paclitaxel for the treatment of adults with platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer who have received one to three prior systemic treatment regimens, at least one of which included bevacizumab.

Criteria

Lifyorli

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of one of the following:
• Epithelial ovarian cancer
• Fallopian tube cancer
• Primary peritoneal cancer
AND
• Disease is platinum resistant [A]
AND
• Used in combination with nab-paclitaxel
AND
• Patient has received one prior bevacizumab-containing systemic treatment regimen
AND
• Patient has not received more than three prior systemic treatment regimens (e.g., chemotherapy) [B]

Lifyorli

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy

Lifyorli

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of one of the following:
• Epithelial ovarian cancer
• Fallopian tube cancer
• Primary peritoneal cancer
AND
• Submission of medical records (e.g., chart notes) confirming disease is platinum resistant
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming that requested product will be used in combination with nab-paclitaxel
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming patient has received one prior bevacizumab-containing systemic treatment regimen
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming patient has not received more than three prior systemic treatment regimens (e.g., chemotherapy)

P & T Revisions

1970-01-01, 2026-06-30, 2026-05-08

References

1. Lifyorli Prescribing Information. Corcept Therapuetics Incorporated. March 2026. Accessed April 2026.
2. NCCN Guidelines Version 3.2026 Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. Accessed April 2026.
3. Relacorilant in Combination With Nab-Paclitaxel in Advanced, Platinum-Resistant, High-Grade Epithelial Ovarian, Primary Peritoneal, or Fallopian-Tube Cancer. ClincialTrials.gov ID NCT05257408. Accessed April 2026.

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End Notes

1. Platinum-resistant disease is defined as progression on primary, maintenance or recurrence therapy, or stable or persistent disease (if not on maintenance therapy) or complete remission and relapse <6 months after completing platinum-based chemotherapy (2)
2. Chemotherapy regimens may include carboplatin/paclitaxel, carboplatin/liposomal doxorubicin, carboplatin/docetaxel, bevacizumab (2)

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Revision History

• 2026-06-30: Addition of drug specific non-formulary criteria to guideline
• 2026-05-08: New Program.

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