Short Acting Insulin - ST, NF
Indications for Prior Authorization
Humalog (insulin lispro)
-
For diagnosis of Diabetes Mellitus
Indicated to improve glycemic control in adults and children with diabetes mellitus.
Lyumjev (insulin lispro-aabc)
-
For diagnosis of Diabetes Mellitus
Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.
Novolog (insulin aspart)
-
For diagnosis of Diabetes Mellitus
Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.
Novolin (human insulin)
-
For diagnosis of Diabetes Mellitus
Indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus.
Criteria
Humalog Tempo Pen, Lyumjev Tempo Pen
Step Therapy
Length of Approval: 12 Month(s)
- Requested drug is being used for a Food and Drug Administration (FDA)-approved indication AND
- Trial and failure (of a minimum 30 day supply), contraindication, or intolerance to two of the following:
- Brand Humalog (insulin lispro) or Brand Insulin lispro
- Brand Novolog (insulin aspart)
- Lyumjev (insulin lispro)
- Admelog (insulin lispro)
- Apidra (insulin glulisine)
- Fiasp (insulin aspart)
Novolog Relion, Novolog Flexpen Relion, Novolog Mix 70/30 Relion, Novolog Mix 70/30 Flexpen Relion
Non Formulary
Length of Approval: 12 Month(s)
- Requested drug is being used for a Food and Drug Administration (FDA)-approved indication 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 Novolog/Novolog mix (insulin aspart) AND Fiasp (insulin aspart) AND
- Submission of medical records confirming Novolog/Novolog mix (insulin aspart) AND Fiasp (insulin aspart) have not been effective AND justification/rationale provided explaining how the Non-Formulary or Excluded Medication is expected to provide benefit when the formulary alternatives have not been shown to be effective despite having the same active ingredient
- Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure (of a minimum 30 day supply), contraindication, or intolerance to three of the following:
- Brand Humalog (insulin lispro) or Brand Insulin lispro
- Lyumjev (insulin lispro)
- Admelog (insulin lispro)
- Apidra (insulin glulisine)
Novolin R Relion, Novolin N Relion, Novolin 70/30 Relion
Non Formulary
Length of Approval: 12 Month(s)
- Requested drug is being used for a Food and Drug Administration (FDA)-approved indication 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 Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin) AND
- Submission of medical records confirming Novolin/Novolin mix (human insulin) AND Humulin/Humulin mix (human insulin) have not been effective AND justification/rationale provided explaining how the Non-Formulary or Excluded Medication is expected to provide benefit when the formulary alternatives have not been shown to be effective despite having the same active ingredient
P & T Revisions
2024-06-03, 2023-11-29, 2023-11-22, 2023-11-15, 2023-10-27, 2023-09-06, 2023-08-02, 2023-05-23, 2023-01-06, 2022-06-01, 2022-04-29, 2022-03-10, 2022-02-03, 2021-07-19, 2021-05-24, 2020-10-28, 2020-08-20, 2020-05-29, 2020-04-17, 2020-03-18, 2020-01-27, 2019-12-17, 2019-10-17
References
- Novolog Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. February 2023.
- Humalog Prescribing Information. Lilly USA, LLC. Indianapolis, IN. August 2023.
- Novolin Prescribing Information. Novo Nordisk Inc. Plainsboro, NJ. November 2022.
- Lyumjev Prescribing Information. Lilly USA, LLC. Indianapolis, IN. October 2022.
Revision History
- 2024-06-03: 2024 UM Annual Review. Updated NF criteria for Novolog and Novolin products.
- 2023-11-29: Addition of Brand Insulin lispro as a preferred alternative
- 2023-11-22: Updated guideline effective date to 1/1/24.
- 2023-11-15: Updated guideline
- 2023-10-27: Program update to remove Admelog, Apidra, Fiasp, Novolog, Novolin as targets.
- 2023-09-06: update guideline
- 2023-08-02: Added Novolog Penfill to NF criteria
- 2023-05-23: Removed Novolog products from ST guideline as they were moved to ABA PA guideline.
- 2023-01-06: Added Humalog & Lyumjev tempo pen to mirror Admelog criteria. Updated lyumjev indication section and references.
- 2022-06-01: Annual review: No criteria changes, updated references.
- 2022-04-29: GPI Reclassification
- 2022-03-10: Updated GL name to include "-ST, NF"
- 2022-02-03: Added NF criteria for excluded insulin products. Updated references and background.
- 2021-07-19: Update to add Novolog Relion products as targets
- 2021-05-24: Annual review: updated references
- 2020-10-28: Lyumjev moving to preferred.
- 2020-08-20: insulin step to include Lyumjev as a step target
- 2020-05-29: Annual review, no changes to clinical criteria updated references. 5.29..2020 - updated new GPI in products section (added GPI 2710400500D2222)
- 2020-04-17: Added Insulin lispro junior (ABA for Humalog Jr) and insulin lispro protamine 75/25 (ABA for Humalog Mixpen) as targets to the step.
- 2020-03-18: updated reference
- 2020-01-27: Modified indication and references section due to updated indication (To improve glycemic control in adult and pediatric patients with diabetes mellitus.) No criteria changes
- 2019-12-17: Added insulin aspart, the ABA for Novolog to bucket with ABA insulin lispro & added Brand before the word novolog for bucket that has insulin aspart
- 2019-10-17: New Penfil 100/mL cartridge. Add as a target in the short-acting insulin ST guideline to the section that requires both Humalog AND Novolog.
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