Pharmacy Prior Authorization Criteria

Long Acting Insulins - PA, NF

Indications for Prior Authorization

Levemir (insulin detemir)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus.

  Limitations of Use: Levemir is not recommended for the treatment of diabetic ketoacidosis.

Tresiba (insulin degludec)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.

  Limitations of Use: Not recommended for the treatment of diabetic ketoacidosis.

Semglee (insulin glargine), Semglee (insulin glargine-yfgn), Insulin glargine-yfgn, Rezvoglar (insulin glargine-aglr)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Basaglar (insulin glargine)

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Insulin degludec

• For diagnosis of Diabetes Mellitus
  Indicated to improve glycemic control in patients 1 year of age and older with diabetes mellitus.

  Limitations of use: Not recommended for the treatment of diabetic ketoacidosis.

Criteria

Levemir, Tresiba

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of diabetes mellitus
AND
• Trial and failure of a minimum 30 days supply, contraindication, or intolerance to one of the following:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)

Basaglar, Insulin Glargine, Insulin Glargine-yfgn, Rezvoglar, Semglee

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of diabetes mellitus
AND
• Both of the following:
• Submission of medical records (e.g., chart notes) confirming the patient has experienced intolerance (e.g., allergy to excipient) with both of the following formulary alternatives that have the same active ingredient:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)
AND
• Submission of medical records (e.g., chart notes) confirming the formulary alternative(s) has not been effective AND valid clinical rationale provided explaining how the Non-Formulary or Excluded Medication is expected to provide benefit when the formulary alternative has not been shown to be effective despite having the same active ingredient
AND
• Submission of medical records (e.g., chart notes or paid claims confirming a minimum 30 days supply, contraindication, or intolerance to Tresiba (insulin degludec)

Insulin Degludec

Non Formulary

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming diagnosis of diabetes mellitus
AND
• Both of the following:
• Submission of medical records (e.g., chart notes) confirming the patient has experienced intolerance (e.g., allergy to excipient) to Tresiba (insulin degludec)
AND
• Submission of medical records (e.g., chart notes) confirming Tresiba (insulin degludec) has not been effective AND valid clinical rationale provided explaining how the Non-Formulary or Excluded Medication is expected to provide benefit when the formulary alternative has not been shown to be effective despite having the same active ingredient
AND
• Submission of medical records (e.g., chart notes) or paid claims confirming a minimum 30 days supply, contraindication, or intolerance to both of the following:
• Lantus (insulin glargine)
• Toujeo (insulin glargine)

P & T Revisions

2024-06-05, 2023-05-25, 2023-02-09, 2022-06-17, 2021-07-06

References

1. Levemir Prescribing Information. Novo Nordisk Inc. Plainsboro, New Jersey. December 2022.
2. Tresiba Prescribing Information. Novo Nordisk Inc. Plainsboro, New Jersey. July 2022.
3. Basaglar Prescribing Information. Eli Lilly and Company. Indianapolis, IN. July 2021.
4. Semglee Prescribing Information. Mylan Specialty L.P. Morgantown, WV. October 2022.
5. Insulin Glargine-yfgn Prescribing Information. Mylan Specialty L.P. Morgantown, WV. July 2021.
6. Rezvoglar Prescribing Information. Eli Lilly and Company. Indianapolis, IN. March 2024.

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Revision History

• 2024-06-05: Addition of NF criteria for excluded EHB products
• 2023-05-25: 2023 Annual Review - updated references
• 2023-02-09: Added new Levemir Flexpen formulation to guideline. No changes to criteria.
• 2022-06-17: Annual review: no criteria changes.
• 2021-07-06: New program

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